Health Information Management

Q&A: Determining whether a physician query is leading

JustCoding News: Inpatient, November 11, 2009

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QUESTION: Is it appropriate to query a physician for which diagnosis he or she wants to be a patient’s principal diagnosis? For example, is the following 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 physician query be considered leading? Should the coder refrain from giving the physician choices for the principal diagnosis?

ANSWER: Coders should not pose queries in a format that the physician could answer with a yes or no response unless it is regarding a present on admission indicator, per the October 2008 American Health Information Management Association (AHIMA) practice brief titled, “Managing An Effective Query Process.” (To view the AHIMA practice brief, click here. Then click on “All current practice briefs in chronological order by publication date” and scroll down to the brief.)

It is appropriate to query a physician to identify which diagnosis you should sequence as the principal diagnosis, however, I would recommend asking a more open-ended question for clarification.

When a coder determines that two conditions equally meet the criteria for admission but the physician is not clear about which should be the principal, then a query may be warranted. Coders should provide all of the patient’s information for the physician to review in the query, and they should ask the physician to indicate which diagnosis in his/her professional opinion should be principal.

The two diagnoses referenced above (CHF and COPD) group to different MS-DRGS, and the relative weights differ. It is inappropriate for a coder to indicate which diagnosis pays at a higher rate in the query.

A query is generally 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, “The principal diagnosis should be COPD, correct?” would be a leading query and must be avoided.

Editor’s note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA, answered this question.

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



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