Health Information Management

Note details when drafting physician queries

HIM-HIPAA Insider, June 7, 2011

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Coders should be mindful of the words they choose when drafting physician queries. Certain words—or their absence—can increase the likelihood that physicians will respond with the desired clarification. Consider the following techniques to boost the effectiveness of your queries:

  • Identify the source of information. When citing information directly from a chart, use quotation marks and identify the source, says Andrew Rothschild, MD, MS, MPH, FAAP, CCDS, clinician and director at FTI Healthcare in Atlanta. "I always recommend using quotes," he says. "If you don't use quotes, the physician often believes that you're interpreting. Without quotes, it seems as though you're noticing something that wasn't necessarily documented in the chart." Preface queries with phrases such as "per nursing" or "per radiology," says Rothschild. This calls physicians' attention to a specific area of the chart, which he recommends flagging to facilitate access.
  • Consider the query title. Even query titles can be leading, says Cheryl ­Ericson, MS, RN, manager of the clinical documentation integrity and utilization review departments at the Medical University of South Carolina in Charleston. For example, the title is "Query for acute blood loss anemia" and the query asks the physician to clarify the type of anemia. This can ­confuse physicians, who may even be tempted to document acute blood loss anemia, she says. A general approach is best.
  • Information may not be ­readily available. Prefacing a query with "when possible, please clarify" acknowledges that coders realize information may not be available currently and that the physician should answer the query when it is available, says Rothschild.
Editor’s note: For additional tips, see the June issue of Briefings on Coding Compliance Strategies on the HCPro website.

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