Topic: Physician queries-Ask the right questions to improve coding accuracy, obtain detailed documentation
HIM Connection, January 8, 2008
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The physician query process allows coders to clarify documentation for accurate code assignment. To generate a query, coders must ask physicians to explain inconsistent or vague documentation regarding a patient's diagnosis or treatment. However, clinician clarification is a delicate matter, and coders should seek it only when absolutely necessary. To keep the lines of communication smooth and tension-free, it's important to approach queries with tact and to be thoughtful so as not to lead the physician toward a certain diagnosis.
When deciding whether to query, Alison Nicklas, manager for the Healthcare Advisory Consulting Practice for PricewaterhouseCoopers in Albany, NY, said to first ensure that the documentation in the record supports the query. Coders should examine the entire clinical picture-including the medication record, physician orders, nursing records, and any ancillary department notes. Examining these documents can help support the query, and it can also help avoid an unnecessary query. "You want to be certain you didn't miss anything," said Nicklas. "It's very embarrassing when you ask a physician to clarify something, and he or she becomes irritated because they already documented it in a progress note."
Coders should also ask open-ended questions whenever possible. If this isn't an option, they should provide physicians with several reasonable choices. Coders should never indicate a preference for a particular diagnosis. Coders also need to understand their role and remember that clinical documentation is the physician's responsibility. Under no circumstances should coders attempt to make any medical assumptions.
Editor's note: This tip is adapted from an January, 2008 article in Briefings on Coding Compliance Strategies. For more information, click here.
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