Health Information Management

Ensure compliance when it comes to verbal queries

HIM-HIPAA Insider, January 27, 2009

Verbal queries have the greatest liability from a legal standpoint and because they are a common source of miscommunication, says Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, president of Safian Communications Services, Inc., in Winter Park, FL, and a member of AHIMA’s National Classification Practice Counsel. Your policy must clearly state that verbal answers to verbal queries do not constitute documentation. The physician’s response must appear in writing (or electronically) in the record.

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