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Physician Query Basics and When to Query

Physician Query Basics and When to Query

by Christopher G. Richards, RHIA, CCS

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 … Read more

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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

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 …

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

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

by Christopher G. Richards, RHIA, CCS

We talk about consistency with regards to either differing diagnoses between two or more providers or we might also be referring to documentation of clinical indicators, diagnostic tests, and treatment but no related “after study” condition documented. Read more

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Documentation Clarity and an Example of how a Good Physician Query is Developed

Documentation Clarity and an Example of how a Good Physician Query is Developed

by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.

When we talk about clarity, we might be referring to an instance where a diagnosis is stated without documentation of cause or suspected cause or there is no clinical validation. We might need clarification of a potential cause and effect relationship that directly impacts how a coder … Read more

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Specific Examples of Common Query Scenarios and Four Key Aspects of Documentation

Specific Examples of Common Query Scenarios and Four Key Aspects of Documentation

by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.

Completeness simply refers to the problems that are created for the coder when specific pieces of documentation are missing from the medical record. This could include the missing test results. For example … Read more

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