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Physician querying is a must for accurate charting

Case Management Weekly, March 18, 2008

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The best way for your hospital's documentation to be accurate is for physicians to take their time with it the first time around and to be as thorough as possible.

But that often isn't the case; even when it is, case managers will often have questions about a specific patient that can only be answered by the physician.

The best way to clarify these questions and to ensure your documentation will get you full reimbursement is to set up a physician query program, said Lynn Spryszak, RN, and Heather Taillon, RHIA, during the January 21 HCPro, Inc., audioconference, "Clinical Documentation Improvement (CDI) Process: Best practices for a successful program."

When creating a system for physician queries, the most important thing to do is maintain strong, open lines of communications with nurses, coders, and physicians, said Taillon, manager of coding compliance at St. Francis Hospital in Beech Grove, IN. Having a case manager who has good communication skills and is confident in clinical knowledge serve as a clinical documentation specialist (CDS) may make this process run smoother, she said.

Source: To read more about this story, take a look at the March 2008 issue of Case Management Monthly

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