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, a query can be a powerful communication tool used to clarify documentation in a health record and achieve accurate code assignment. 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.

So how do you as a coding professional ensure that your queries are effective and compliant? First, it’s important to understand when to query a physician. 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
  • A diagnosis without an underlying clinical validation
  • Unclear POA (present on admission) indicators

We are all experienced professionals who read health record after health record after health record. Sometimes it can be easy to fall into the trap of “playing doctor.” Many times, we may see a connection that wasn’t actually documented by the physician, and this can mean that the information is not as complete as it could be – or we may end up coding something that can’t be supported in the record due to an assumption.

This is a good reason to generate a query. 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.

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

  1. 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 follow unless the physician requests a reason for the query. Remember, the goal of a query is to make the record clearer, nothing more.
  2. 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?”
  3. 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.”
  4. 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 always provide the physicians with multiple answer options – and always include an “out” such as “unable to be determined.” This will aid in the query being compliant.    
  5. Avoid Yes/No questions. Writing a query in such a way that a physician can answer simple “yes” will leave you asking yourself “yes, what?” Was the condition ruled out? Does the patient still have that condition? Again, always offer response options, if you can.
  6. Quote the medical record word-for-word. When you quote word-for-word what was stated in the documentation that was in question, you avoid the risk of introducing information that was never there, to begin with. Which leads to the next tip…
  7. Never introduce new information. In a query, you should not ask a direct question about something that was never diagnosed without giving the physician an open choice.
  8. And last but not least, reread your query and ask yourself: Should this query be sent? Is this query clear and concise? Does this query solicit an answer that I can code? If you answer no to any of these questions, re-work the query or don’t query at all.

Programming Note:

Listen in to Terry Fletcher’s report this story live today during  Talk Ten Tuesday.

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