Health Information Management

Determine when and how to query physicians

HIM-HIPAA Insider, March 17, 2014

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Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.

Both coders and CDI specialists can query physicians when documentation:
  • Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
  • Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
  • Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
  • Provides a diagnosis without underlying clinical validation
  • Is unclear for POA indicator assignment
Query guidance requires continual review and updates to reflect best practices. "Everyone is getting more sophisticated in their querying," says Cheryl Ericson, RN, MS, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro, a division of BLR, in Danvers, Mass. "Patients are getting sicker. There are a lot of complexities that we need to capture."
In February 2013, AHIMA and the Association for Clinical Documentation Improvement Specialists (ACDIS) jointly released Guidelines for Achieving a Compliant Query Practice, which provides information about how and when to query.
Continue reading "Determine when and how to query physicians" on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies  have free access to this article in the March issue.

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