by Chris Richards, RHIA, CCS
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.
• 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 _________________
• Clinically irrelevant__________________________
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.
Timing of a Physician Query
- 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