by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.
Here are some basic query guidelines:
- Physician queries should focus on conditions or diagnoses already established in the medical record. A query should not introduce NEW information or information from another admission. Your focus is on accurately coding the current admission.
- Queries apply to ALL payer types regardless of the impact on reimbursement. The focus must be on the data quality with respect to accurate code assignment. Queries are NOT just for DRG assignment.
- A compliant query should seek clarifications based on a statement of the facts found in the record that you as the coder turn into a question for the physician to answer. A compliant query asks the physician to clarify existing documentation/facts present in the record.
- A compliant query should not and must not be “leading” in nature.
What do we mean when we talk about avoiding “leading queries?”
“A query is never intended to lead the provider to one desired outcome. The query must provide reasonable, clinically supported options, include clinical indicators, and must not result in a yes/no*. They must include the option that no additional documentation or clarification can be provided.”
*There are a couple exceptions (as always) to the yes/no rule, discussed later.
Example of a Leading Query
Dear Dr. Jones,
Based on your documentation, this patient has anemia and was transfused 2 units of blood. Also, there was a 10 point drop in hematocrit following surgery.
Please document “acute blood loss anemia,” as this patient clearly meets the clinical criteria for this diagnosis.
This is non compliant and will lead to trouble. The query intent is NEVER to tell the physician to document something.
Just like on Jeopardy, a query must BE IN THE FORM OF A QUESTION!
Appropriate Use Of Yes/No Physician Queries
- AHIMA Practice Brief: Managing an Effective Query Process, 2008
- AHIMA Practice Brief: Ensuring Legibility of Patient Records, 2003
- AHIMA Practice Brief: Guidance for Clinical Documentation Improvement Programs, 2010
Attn: CDI specialists! Libman Education’s ICD-10 Documentation Quick Reference Guide is the one reference you need to help your physicians get it right. Help ensure your documentation provides sufficient detail to allow complete and accurate coding. Learn more here.