by Chris Richards, RHIA, CCS
- Quality of coding is dependent on quality of documentation
- Query is a communication tool between coders and clinicians
- Fact-based to clarify documentation and improve data quality/integrity
- Components include language, timeliness, relevance and compliance
- Policies and procedures are key to success
The physicians are busy. Their job is to care for their patients. You are going to have physicians who may seem more than willing to assist you in your quest to accurately code every record. You are also going to encounter physicians who have zero interest in being bothered with respect to your queries.
Yours is a balancing act. As you’ll hear, “sometimes you have to pick your battles.” Everyone who relies on physician documentation to do their jobs has to consider this in deciding when and when NOT to initiate a physician query. There are many models out there that help coders develop query programs and you are advised to explore some of the different approaches, while recognizing that what works for one may not work for all.
In the final analysis, you have questions related to the documentation and the physicians frequently possess the answers to your questions. High on the recommendations list is a physician liaison, a champion, whatever you wish to call him or her, who can help bridge the physician query gap. From the coder’s perspective, you need to carefully refine your communication skills when interacting with busy physicians. Only when you develop and nurture relationships with your physician staff, will you find those ever so tactful ways to get the information you need in the most efficient and collaborative manner.
- 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