Documentation Precision and an Example of How a Good Physician Query is Developed

Documentation Precision and an Example of How a Good Physician Query is Developed

by Chris Richards, RHIA, CCS

Precision
We talk about precision in the context of documentation of an unspecified diagnosis when clinical reports and clinical documentation is noted to suggest a more specific diagnosis. For coding purposes, there exists a need to request further specificity or the degree of severity of a documented condition.

Example of Precision issue:
A patient is admitted for a right hip fracture. The H&P notes that the patient has a history of chronic congestive heart failure. A recent echocardiogram showed left ventricular ejection fraction (EF) of 25%. The patient’s home medications include metoprolol XL, lisinopril, and Lasix.

Precision query:

It is noted in the impression of the H&P that the patient has chronic congestive heart failure and a recent echocardiogram noted under the cardiac review of systems reveals an EF of 25 percent. Can the chronic heart failure be further specified as:

• Chronic systolic heart failure____________________
• Chronic diastolic heart failure___________________
• Chronic systolic and diastolic heart failure__________
• Some other type of heart failure _________________
• Undetermined_____________________________
• Clinically irrelevant__________________________

Comments ___________________________________________________

Note the comments line – 2 important query guidelines

• always offer an undetermined option.
• always offer an opportunity for the physician to provide a comment.

The CHF example is certainly an excellent example of a precision query. The query is just a restatement of the known facts and asks for a further specificity to allow precision in assigning the correct code. You are simply requesting more precision for a diagnosis already documented and established.

Next:
Timing of a Physician Query

 

References:

  • 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

 

About the Author

Chris Richards, RHIA, CCS
Chris joined Barry Libman Inc. as a Senior Associate in 2014 after 27 years with Masspro, the Massachusetts Quality Improvement Organization (QIO). Chris’s areas of expertise include health information administration, case management, quality improvement, hospital payment oversight, and documentation education initiatives. He has a comprehensive understanding of the Federal Medicare program rules and regulations, as well as extensive experience ensuring that clinical coding and DRG assignment result in accurate provider reimbursement. A graduate of Hobart College, he received a postgraduate Bachelor of Science in Health Information Administration from Northeastern University.

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