Health Information Management

Sample query note: How to construct appropriate queries for bowel disease

CDI Strategies, May 28, 2009

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When you suspect a patient who was discharged with a diagnosis of inflammatory bowel disease may actually have Crohn’s disease or ulcerative colitis, query the physician, says Helen Walker, MD, vice president of clinical quality for FairCode Associates in Towson, MD.
 
Walker provided the following sample letter you can adapt to your needs (Note: consult your compliance department before implementing any changes to your query process):
Dear Dr. Jones,
The medical record documentation requires clarification for accurate coding. The patient presented with diarrhea, fever and weight loss, had oral aphthous ulcers on exam, was found to have inflammation and focal ulcerations in the colon on colonoscopy, and was treated with Sulfasalazine. This patient’s discharge diagnosis was inflammatory bowel disease. Inflammatory bowel disease codes to noninfectious gastroenteritis and colitis. 
 
Please provide clarification whether noninfectious gastroenteritis and colitis accurately describes this patient’s condition, or if there is another condition that should be listed instead.
 Editor’s note: The above excerpt is from Walker’s upcoming article in the July 2009 issue of CDI Journal, a quarterly publication available to ACDIS members.



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