According to AHIMA, a query can be a powerful communication tool used to clarify documentation in the health record and achieve accurate code assignments. Querying has become a common communication and educational tool for clinical documentation improvement (CDI) and coding departments. An effective query process aids the hospital’s compliance with billing/coding rules and serves as an educational tool for providers, CDI professionals, and coding professionals.
So how do you as a coding professional ensure your queries are effective and compliant? First, it’s important to understand when to query a physician. AHIMA guidelines state that a query should be considered when health record documentation includes:
- Conflicting, imprecise, incomplete, ambiguous or inconsistent documentation
- Associated clinical indicators related to a specific condition
- A diagnosis without an underlying validation clinically
- Unclear POA
We are all experienced professionals that read health record after health record after health record. Sometimes it can be easy to fall into the trap of “playing doctor.” Many times, we may see a connection that isn’t documented and this can mean that the information is not as complete as it could be. This is a good reason to generate a query. However, it is also possible to read too far into the documentation and make connections that don’t really exist. Before submitting a query, stop and consider the appropriateness. AHIMA has some great query examples in the Journal of AHIMA online.
Following are some tips to help you write effective, compliant queries.
- Queries are not the time to educate physicians about coding. We should not include ICD-10-CM/PCS codes, code details or coding guidelines or rules that we follow unless the physician requests a reason for the query. Remember, the goal of a query is to make the record clearer, nothing more.
- Use a consistent, compliant format. Often, introductions are skipped in a query, but you should use the introduction to explain why the patient was being seen/admitted, then present the clinical picture, quote the documentation in question, ask the question, and provide response options.
- Have clear titles. Titles of queries should be generic. Don’t ask questions or offer options in the title. For example, a good title would be “CHF Type” as opposed to “CHF systolic or diastolic.”
- Make sure your question is clear. Be direct in what you are asking without being leading. Make queries simple and to the point without too much “clutter.”
- Offer response options. Never tell the physician what to write, no matter how clear the clinical picture appears. Be sure to ask clear questions and always provide the physicians with multiple answer options and always include an “out” such as “unable to be determined.” This will aid in the query being compliant.
- Be professional. Although this can be a matter of taste or communication style, it is recommended to avoid personal pronouns like I or we and be more formal and less personal.
- Be concise. If your queries get too wordy and cluttered, they become confusing and you may not get the information you need from the physician.
- Put the question last. Ask only one question in the query and make it the last statement before providing the response options.
- Avoid Yes/NO questions. Writing a query in such a way that a physician can answer simply “Yes,” will leave you asking yourself “Yes, what?” Was the condition ruled out? Does the patient still have that condition? Again, always offer response options.
- Quote the medical record word-for-word. When you quote word-for-word what was stated in the documentation that was in question, you avoid the risk of introducing information that was never there to begin with. Which leads to the next tip …
- Never introduce new information. In a query, you should not ask a direct question about something that was never diagnosed without giving the physician an open choice.
- Last but not least, re-read your query and ask yourself: Should this query be sent? Is this query clear and concise? Does this query solicit an answer that I can code? If you answer no to any of these questions, re-work the query or don’t query at all.
There’s a lot to keep in mind when querying physicians (visit our previous blog post for tips on a few areas where the need for more specific documentation has been impacted by ICD-10). But following these tips will help to ensure that your queries are appropriate, effective, clear, and compliant. What tips do you have for creating physician queries? Share them in the comments section below.