Health Information Management

Q&A: Crafting a query that doesn’t include leading statements

JustCoding News: Inpatient, January 20, 2010

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QUESTION: I am coding a new admission to our nursing home. The physician documented a very short history and physical (H&P): "Suffered aneurysm December 2008 had clipping, ventriculoperitoneal shunt (VP) shunt, significant deficits noted." How should I phrase the query to the physician to elaborate on the deficits? The nursing notes from the hospital stay state, “Right-sided weakness, mental and speech impairments.” I’m just concerned about how to word the query because I know coders aren't supposed to pose leading statements.

ANSWER: This question is about tact. Let physicians know that part of your job is to watch their backs regarding compliance with certain legal documentation issues. Convey to them that you understand they are incredibly busy, but because you want to protect them and avoid any possible legal ambiguities, you are requesting that they elaborate further on this admitting H&P. Share with physicians that additional specifics about the deficits are required to support medical necessity for the admission, present on admission documentation, as well as to support ancillary services such as speech or physical therapy for this patient.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at

This answer was provided based on limited information submitted to Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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