Health Information Management

Q&A: Querying for principal diagnosis

HIM Connection, January 26, 2010

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Q: Is querying a physician for the principal diagnosis appropriate? For example, is this query appropriate: “Can either congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) be the principal diagnosis for this patient? Please clarify the principal diagnosis.” Would this query be considered leading? Should coders refrain from giving physicians choices for the principal diagnosis?
 
A: Generally, queries should not elicit a yes or no response. Note the following exception. This type of query is permissible when it pertains to a present on admission indicator, according to the October 2008 American Health Information Management Association practice brief, “Managing An Effective Query Process.” (You can access this practice brief at www.ahima.org/infocenter/practice_tools.asp#Briefs. Click on “All current practice briefs in chronological order by publication date” and scroll down.)
 
Querying physicians to identify the diagnosis to sequence as the principal diagnosis is appropriate. Open ended questions are preferable.
 
A query may be warranted when a coder determines that two conditions equally meet criteria for admission but the physician does not clearly state which is the principal diagnosis. Coders should include all of the patient’s information in their queries. They should ask physicians to indicate which diagnosis, in their professional opinion, should be principal.
 
The two diagnoses referenced in the question (CHF and COPD) group to different MS-DRGs, and their relative weights differ. Avoid queries that inform physicians which diagnosis pays at a higher rate because such queries are inappropriate.
 
A query generally is considered leading when the coder includes the answer in the question or when the query is worded in a way that could sway the physician toward a particular code. For example, avoid a leading query such as, “The principal diagnosis should be COPD, correct?”  
 
Editor’s note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc. answered this question in the January issue of Briefings on Coding Compliance Strategies.



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