by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.
What is a physician query?
Simply put, a physician query is a written communication tool that will allow coders to improve the accuracy of coding by actively involving the physician in the documentation clarification process. Full and complete documentation is the essential key to accurate coding. A physician query should present specific facts derived from the medical record and convey clearly to the physician why additional clinical clarification is needed.
Does a physician query have an exact definition?
A physician query is defined as a written question to a physician to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record.
Why do you query a physician?
As stated, you would query a physician to ensure complete and accurate health record documentation. Querying a physician is a vital part of that documentation process.
When do you query a physician?
This is important to ensure an appropriate query and also to avoid unnecessary queries. If coding a record is difficult, ask yourself if the patient’s health record has any:
- Conflicting information
- Ambiguous information
- Incomplete information
- Clinically relevant information not addressed
- Significant reportable condition or procedure
- Lack of clarity for present on admission indicator assignment
If you answered “yes” to any of the above you should consider a physician query.
But – know when NOT to query
Do not query
- to question a provider’s clinical judgment
e.g. chest x-ray is negative but the provider documents clinical pneumonia
- when the benefit is strictly for reimbursement
- when there is clinically insignificant findings or irrelevant information
- when the improvement to data quality is negligible
Value the physician’s time! Know when to NOT initiate a formal query.
Describe General Aspects Of A Compliant 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
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