Chat with us, powered by LiveChat
Physician Query Basics and When to Query

Physician Query Basics and When to Query


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.

Next:
Describe General Aspects Of A Compliant 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

 

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

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.

Comments are closed.