Health Information Management

Take time to review query forms

APCs Insider, June 7, 2013

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By Michelle A. Leppert, CPC

When was the last time you updated your physician query forms? This year? Last year? Not since you created them? Now is a good time to review your query forms and make sure they met the latest AHIMA/ACDIS guidelines and so they are ready for ICD-10.
Coders should consider querying a physician when the health record 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 present-on-admission indicator assignment
AHIMA released "Guidelines for Achieving a Compliant Query Practice," in the February edition of The Journal of AHIMA. The document, created in collaboration with ACDIS Advisory Board member and reviewed by additional ACDIS and AHIMA leadership, represents the latest of industry thought regarding governance of physician query practices.
 
The guidance contains “augments and, where applicable, supersedes” previous information but most notably provides additional clarity regarding the submission of “yes/no”, verbal, and retention policies for queries, and specifies that any “personnel performing the query function” needs to understand the importance of creating a compliant query process.
 
In addition to updating queries to meet the new AHIMA/ACDIS guidelines, facilities and practices should also look at what additional information coders will need to ICD-10. Some queries will be outdated after the transition to ICD-10. For example, coders will no longer need to know if diabetes is controlled or uncontrolled. ICD-10-CM codes don’t use this information.
 
However, they will need to know:
  • Type of diabetes
  • Cause of the diabetes
  • Specific complications or manifestations
  • Drug that caused the diabetes (when due to drugs or chemicals)
In ICD-10-CM, physicians will need to document a Gustilo-Anderson classification for an open fracture. Update your query forms now so physicians get used to documenting that information. It doesn’t hurt to have the information now.
 
You don’t need to roll out all of the new query forms at once. You also don’t need to tell the physicians the additional information is for ICD-10. Just ask them for the details in your queries.



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