how do you write a physician query

Following are some tips to help you write effective, compliant queries:

• Queries are not the time to educate physicians about coding. We should not include ICD-10-CM/PCS codes, code details, or coding guidelines that we ...
• Have clear titles. Titles of queries should be generic. Don’t ask questions or offer options in the title. For example, a good title would be “CHF ...
• Make sure your question is clear. Be direct in what you are asking without being leading. Make queries simple and to the point, without too much ...
• Offer response options. Never tell the physician what to write, no matter how clear the clinical picture appears. Be sure to ask clear questions and ...

Full Answer

What is a physician query?

“A physician query is defined as a written question to a physician to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record.

How do you write an undetermined query for a doctor?

You might also include “undetermined” among the choices if you think the physician could be waiting on the results of diagnostic tests. And pay close attention to the headings you use for physician queries, Williams cautioned, because sometimes headings can cause the query to be leading.

Do Your coders know how to write good physician queries?

If your coders know how to write good physician queries, you can help providers improve their clinical documentation and improve your ICD-10 coding, noted Leonta Williams, RHIT, CPCO, CPC, CEMC, CHONC, CCS, CCDS, who taught the p’s and q’s of queries at 2017’s American Academy of Professional Coders Regional Conference.

Are You Afraid of a physician query?

If there is an issue in the patient documentation that needs clarity, a physician query is necessary, and you should not be afraid of it. Following are some tips to help you write effective, compliant queries: Queries are not the time to educate physicians about coding.

What is a query in health care?

Is yes or no query appropriate for specifying the type of anemia?

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What should be included in a physician query?

A physician query must be clear and concise. It should contain clinical indicators from the health record.

What is the purpose of a physician query?

A physician query is a method of communication used by coders to request clarification of patient diagnoses or procedures from the physician. The purpose of this policy is to improve physician documentation and coders understanding of unique clinical situations.

What is an example of a leading query?

An example of a nonleading query might be: Can you further specify the etiology of the patient's pneumonia? But here's AHIMA's example of a leading query: Is the patient's pneumonia due to aspiration? Such queries can get a hospital in trouble.

What is a leading physician query?

A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure.

What information should be included in a query form?

A query should contain at a minimum:Patient name.Admission date (date of service)Medical record number.Account number.Date query initiated.Name and contact information of the initiator of the query.A statement of the issue (list clinical indicators from the chart or ambiguous/unsubstantiated information)

What makes a query compliant?

Queries must be accompanied by clinical indicator(s) that: Are specific to the patient and episode of care. Support why a more complete or accurate diagnosis or procedure is sought. Support why a diagnosis requires additional clinical support to be reportable.

What is a clinical validation query?

Clinical validation is the process of validating each diagnosis or procedure documented within the health record, ensuring it is supported by clinical evidence in the medical record.

What is an open ended query?

A: An open-ended query works best when the potential answers are limited, when the query involves commonly used terminology, and when physicians are familiar with the type of documentation required. The following is one example of a possible open-ended query: “Dear Dr.

What is the purpose of the physician query process quizlet?

A proper query process ensures that appropriate documentation appears in the health record. Personnel performing the query function should focus on a compliant query process and content reflective of appropriate clinical indicators to support the query.

What is a clinical documentation query?

Documentation queries are sent by the Clinical Documentation Improvement team and Health Information Management in an effort to develop a medical record that accurately reflects the patient's Severity of Illness (SOI), Risk of Mortality (ROM), and the care being provided.

What is the difference between a leading query and non leading query?

“A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure…” One way a physician query would be considered leading is by the introduction of a new diagnosis in the query.

What is a query coding?

In standard English, a query means a request for information. In computer programming, it refers to the same thing, except the information is retrieved from a database. However, writing a query requires a set of pre-defined code to make the database understand the instruction.

Why is a physician query process necessary quizlet?

A proper query process ensures that appropriate documentation appears in the health record. Personnel performing the query function should focus on a compliant query process and content reflective of appropriate clinical indicators to support the query.

What is the role of queries in the CDI process?

DEFINITIONS: Query: A query is an established mechanism of communication between CDI Specialists/Coders and physicians to clarify ambiguous, incomplete or conflicting documentation in the medical record.

What is a clinical documentation query?

Documentation queries are sent by the Clinical Documentation Improvement team and Health Information Management in an effort to develop a medical record that accurately reflects the patient's Severity of Illness (SOI), Risk of Mortality (ROM), and the care being provided.

What is the importance of running queries and reports of healthcare data?

Measure the quality, safety, severity of illness, and efficacy of care. Manage care and disease processes. Track public health and risks. Provide data to consumers regarding costs, quality, and treatment option outcomes.

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Guidelines for Achieving a Compliant Query Practice (2019 Update)

Guidelines for Achieving a Compliant Query Practice (2019 Update) Editor’s Note: This Practice Brief supersedes the January 2016 Practice Brief titled “Guidelines for Achieving a Compliant Query Practice (2016 Update).” This American Health Information Management Association – Association of Clinical Documentation Improvement Specialists (AHIMA-ACDIS) Practice Brief should serve as an ...

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Why do you write a physician query?

You write a physician query when something about the physician’s documentation is confusing you. “It could be lots of different things,” says Jackie Stack, BSHA, CPC, CPMA, CPC-I, CPB, CEMC, CFPC, CIMC, COPC, CPEDC, a practice optimization and documentation expert at Eye Care Leaders. “But it’s basically something that’s going to prevent the claim from getting paid.” Queries can also help you catch errors before they turn into denials, reducing the time staff spends working on appeals. “You want to catch those things and query the provider so you can fix the problem and submit a clean claim to the payer,” Stack says.

What is a query in healthcare?

Like its name suggests, a query is always presented to the provider as a question. It includes specific clinical information from a patients chart, and asks the physician to clarify that information in some way. A query never introduces new information or patient information from a prior visit.

What is query tracking?

The query tracking can help you discern patterns that help you build your CDI program. For example, you might enlist the physician who is queried least often to be your CDI champion. If you and the doctors work together, you’ll see a return on investment that includes better documentation, less back-and-forth time wasted, faster claims submissions, reduced denials, and fewer appeals.

What are the elements of a query?

A query should contain at least these 7 essential elements: Patient name. Date of service. Medical record/account number. Provider’s name. name and contact of the individual sending the query. Date of query.

Why do we need queries?

Queries can also help you catch errors before they turn into denials, reducing the time staff spends working on appeals. “You want to catch those things and query the provider so you can fix the problem and submit a clean claim to the payer,” Stack says.

Why do you include "undetermined" in a query?

And pay close attention to the headings you use for physician queries, Williams cautioned, because sometimes headings can cause the query to be leading.

Can coders write good physician queries?

If your coders know how to write good physician queries, you can help providers improve their clinical documentation and improve your ICD-10 coding, noted Leonta Williams, RHIT, CPCO, CPC, CEMC, CHONC, CCS, CCDS, who taught the p’s and q’s of queries at 2017’s American Academy of Professional Coders Regional Conference. But if you think any old questions will do, think again. Below, we show you how to write compliant queries that get you the answers you need.

What is a leading query?

A leading query is one that is not supported by the clinical elements in the health record that makes one think a more complete or specified diagnosis or procedure is present.

What is a yes/no query?

Coders and CDI specialists should not use a yes/no query when clinical indicators of a condition are present but the physician has not documented the condition/diagnosis in the record. In short, don't introduce a new diagnosis with a yes/no query format. However, yes/no queries, per the AHIMA/ACDIS guidelines, are appropriate in the following circumstances: 1 Substantiating or further specifying a diagnosis that is already present in the health record (e.g., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician 2 Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings (e.g., hypertension and congestive heart failure, diabetes mellitus, and chronic kidney disease) 3 Resolving conflicting documentation from multiple practitioners

Why are retrospective queries different from concurrent queries?

Retrospective queries are very different because coders or CDI specialists are asking physicians to reopen a record and try to remember a particular patient or a particular thought process. Whenever possible, concurrent queries are better, says Elion. Queries can be in multiple-choice format or yes/no format.

Why should verbal queries be retained?

Verbal queries should contain the same clinical indicators as written queries and be retained in the same manner and format to ensure compliance and consistency with policies and processes , Ericson says. "There is nothing against verbal querying; there just has to be some kind of record or memorialization of what transpired during that conversation. We want to make sure that we're not leading the physician or introducing new information during that verbal interaction."

When a practitioner documents a diagnosis that does not appear to be supported by clinical indicator (s), should a?

When a practitioner documents a diagnosis that does not appear to be supported by clinical indicator (s), coders or CDI specialists should query to address the conflict , Ericson says.

How many clinical indicate are needed for a CDI?

Coders and CDI specialists only need one clinical indicate present in order to support a query, but more than one may be present.

What happens if documentation occurs directly into the health record?

If documentation occurs "directly into the health record and there is lack of supporting clinical information, it is recommended the practitioner provide the clinical rationale for the diagnosis (e.g., patient transfused four days ago due to acute blood loss anemia) unless the query is maintained as a permanent part of the health record," according to the AHIMA/ACDIS practice brief.

What is the art of physician query?

The Art of the Physician Query. An effective query process aids the hospital’s compliance with billing/coding rules. According to the American Health Information Management Association ( AHIMA ), Centers for Medicare & Medicaid Services (CMS), AAPC, the American Medical Association (AMA), and many other authoritative sources, ...

What is a query in healthcare?

According to the American Health Information Management Association ( AHIMA ), Centers for Medicare & Medicaid Services (CMS), AAPC, the American Medical Association (AMA), and many other authoritative sources, a query can be a powerful communication tool used to clarify documentation in a health record and achieve accurate code assignment.

What is querying in coding?

Querying has become a common communication and educational tool for clinical documentation improvement (now integrity, or CDI) and coding departments . An effective query process aids the hospital’s compliance with billing/coding rules and serves as an educational tool for providers, CDI professionals, and coding professionals, on the physician side.

What is a query in AHIMA?

AHIMA guidelines state that a query should be considered when health record documentation includes the following: Conflicting, imprecise, incomplete, ambiguous, or inconsistent documentation. Associated clinical indicators related to a specific condition.

What is a good title for a query?

Have clear titles. Titles of queries should be generic. Don’t ask questions or offer options in the title. For example, a good title would be “CHF Type” as opposed to “CHF systolic or diastolic?”

How to ask a question without being leading?

Make sure your question is clear. Be direct in what you are asking without being leading. Make queries simple and to the point, without too much “clutter.”

Can you read too far into patient documentation?

However, it is also possible to read too far into the documentation and make connections that don’t really exist. So before submitting a query, stop and consider the appropriateness. If there is an issue in the patient documentation that needs clarity, a physician query is necessary, and you should not be afraid of it.

What is a Physician Query?

The American Health Information Management Association (AHIMA) defines a physician query as “a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment for an individual encounter in any healthcare setting.”

How long to query a provider?

It’s usually better to query a provider as soon as possible—typically groups are unable to hold charges for longer than five days before sending out claims. Our customers have noted that queries coming from co-workers and internal resources are often better received than those coming from a payer or vendor.

What is querying providers?

Querying providers is an efficient method to ensuring accurate HCC coding, which will lead to improvements in risk adjustment performance and more accurate reimbursements. Set up a 15-minute meeting to learn more.

What is the first step in a query process?

Working with many organizations, we’ve learned the first step is always creating organizational policies and procedures for the query process. Query practices then need to be managed and monitored for compliance and tracking. Once in place, provider education about the importance of queries is needed to drive adoption and responsiveness.

Should physician queries be directed towards a specific diagnosis or procedure?

Physician queries should not steer the provider towards a specific diagnosis or procedure. They should also never indicate the impact on reimbursement, payment methodology, or quality metrics.

What is a Query?

So, what in the world is a query (besides a word that drives me crazy and makes your skin crawl) anyways?

Why do physicians need to be educated?

Physicians need to be educated on how to document and respond with documentation to help coders accurately assign codes. Most of all, everyone has to be patient with each other. We are all on the same team here. We just need to learn each other’s language.

What does a coder do when you ask for clarification?

When a coder sends you a query to clarify information in the chart, they are looking for a code to assist them in painting the patient’s clinical picture. It’s unlikely that they’re questioning your clinical care or judgments, but rather searching out a clarification of which code is most appropriate to reflect the care you’ve provided.

Can a physician track the volume of queries?

They can track the volume of queries by physician (education needs)

Who hunts down a physician?

Whether you are a physician who practices medicine in the inpatient or outpatient setting, you have probably been hunted down by a medical biller, coder, or clinical documentation improvement specialist.

Do physicians need to provide a clinical rationale?

Physicians are eager to provide a clinical rationale for the query. Several paragraphs regarding clinical judgment and rationale take up too much of your time and is not what the coders need and/or want to complete their task.

What is a query in health care?

A query can be a powerful communication tool used to clarify documentation in the health record and achieve accurate code assignments. This Practice Brief In Addition provides examples of the different forms of queries available to HIM professionals.

Is yes or no query appropriate for specifying the type of anemia?

Rationale: In this example, a yes/no query is not appropriate for specifying the type of anemia. A multiple-choice or open-ended query is a better option.