Case Management

Tip: Query forms bridge the gap when coders, physicians speak different languages

Case Management Weekly, October 3, 2012

Coding professionals and physicians often speak two different languages, so a comprehensive query form is essential. 

The documentation physicians provide often does not conform to the coding classification system and does not always allow us to code to capture patient severity, acuity, and accurate reimbursement. Physicians sometimes create their own terminology that is not part of the coding world or included in ICD-9-CM descriptions. In these cases, a query is necessary for clarification. 

Query forms should:
  • Indicate why clarification is necessary
  • Present the scenario
  • State the facts—only the facts
  • Clarify only what is already present in the medical record
  • State a question that asks the physician to make a clinical interpretation 
Query forms should not:
  • Be written on sticky notes or scrap paper
  • Substitute documentation in the medical record
  • Lead the physician
  • Ask questions that can be answered yes or no
  • Indicate the financial impact
  • Require only a physician signature 

Editor’s note: This tip is adapted from Coding and Physician Language: Strategies for Obtaining Complete Documentation, Second Edition published by HCPro, Inc.

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