Avoid leading queries despite lack of AHIMA guidance
Medical Records Briefing, August 1, 2008
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Editor’s note: This article went to press before AHIMA published the final draft of its physician query practice brief. AHIMA plans to publish its final brief in the September and October Journal of AHIMA.
AHIMA states that coders should query when physician documentation is illegible, incomplete, unclear, inconsistent, imprecise, or unreliable. Yet one of the many omnipresent challenges that coders face is how to obtain more thorough documentation in a way that doesn’t lead the physicians toward assumed conditions.
This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Medical Records Briefing.
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