Health Information Management

Ensure compliance when it comes to verbal queries

HIM-HIPAA Insider, January 27, 2009

Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

Verbal queries have the greatest liability from a legal standpoint and because they are a common source of miscommunication, says Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, president of Safian Communications Services, Inc., in Winter Park, FL, and a member of AHIMA’s National Classification Practice Counsel. Your policy must clearly state that verbal answers to verbal queries do not constitute documentation. The physician’s response must appear in writing (or electronically) in the record.

"You can actually watch a doctor put stitches in a patient and count them," Safian says, "but you can’t code it until the doctor writes it down." As the saying often goes, "If it wasn’t documented, it didn’t happen."

Gloryanne Bryant, BS, RHIA, RHIT, CCS, senior corporate director of coding and HIM compliance at Catholic Healthcare West in San Francisco, supports verbal interactions. In fact, she says they’re an effective way to further educate physicians about why querying is crucial and how ICD-9 classifies diseases and procedures. For that reason, she keeps an ICD-9 Manual handy so she can open the book and show visual examples to physicians and other clinicians.

After that, it’s up to the physician to turn the conversation into written documentation. As the AHIMA brief states, "The desired result of a verbal query is documentation by the provider that supports the coding of a condition, diagnosis, or procedure."

Editor’s note: This tip was adapted from the January issue of Briefings on Coding Compliance Strategies. Click here for more information.



Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

Comments

0 comments on “Ensure compliance when it comes to verbal queries

 

Most Popular