Health Information Management

Physician queries: Ask the right questions to improve coding accuracy, obtain detailed documentation

Briefings on Coding Compliance Strategies, January 1, 2008

The physician query process allows coders to clarify documentation for accurate code assignment. To generate a query, coders must ask physicians to explain inconsistent or vague documentation regarding a patient's diagnosis or treatment. However, clinician clarification is a delicate matter, and coders should seek it only when absolutely necessary. To keep the lines of communication smooth and tension-free, it's important to approach queries with tact and to be thoughtful so as not to lead the physician toward a certain diagnosis.

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