Accurate Documentation is Essential – Knowing When to Query your Providers

Accurate Documentation is Essential – Knowing When to Query your Providers

by Pamela J. Haney, MS, RHIA, COC, CIC, CCS

ICD-10 is finally a reality. We have learned to code diagnoses with ICD-10-CM, mastered the root operations in ICD-10-PCS, and we are ready to put our new skills to work.

Documentation challenges plagued us in ICD-9 but become more challenging with ICD-10 due to the increased specificity of the classification system. According to the Office of the Inspector General (OIG), “policies must create a mechanism for HIM/Coding professionals to communicate effectively and accurately with the clinical staff…for proper and timely documentation.” This means we must have a process in place to work with our clinicians to clarify ambiguous documentation. A key part of the query process is knowing when to query!

To identify the correct ICD-10 codes, we must identify conditions that require clinical evaluation, therapeutic treatment, further diagnostic studies, procedures or consultation, extended the patient’s length of stay or increase nursing care and/or monitoring.

A well-designed query will be vitally important for successful coding in ICD-10. Query guidelines to keep in mind:

  • The condition or diagnosis must already be established in the medical record
  • All payer types should be queried, not just those that have an impact on reimbursement
  • The query should just state the facts
  • Queries should not lead the provider to a specific diagnosis

When should coders query the provider? There are a few key questions to ask that may help determine if a query should be initiated:

  1. Is there conflicting information in the medical record? Sometimes documentation in the progress notes may conflict with information in the discharge summary or even another provider’s documentation.
  2. Is there incomplete information in the medical record such as missing test results, progress notes or discharge summary?
  3. Are there any significant reportable conditions or procedures performed that require additional information to be coded correctly?
  4. Is there documentation of an unspecified diagnosis when clinical reports suggest a more specific diagnosis? It may be helpful to request further specificity or the degree of severity of a documented condition.

Just as important as knowing when to query is knowing when NOT to query providers. Queries should not question a provider’s clinical judgment, when the benefit is strictly for reimbursement, or for clinically insignificant findings or irrelevant information.

Queries are an essential communication tool for accurate documentation and quality coding. They should be fact-based to clarify documentation and improve data integrity. Designing a solid query process will help support providers to continually improve their documentation for ICD-10 success.

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Pam Haney

Pam Haney

Pam Haney, MS, RHIA, COC, CIC, CCS, is Director of Training and Education for Libman Education and is responsible for online and instructor-led courses in medical record coding.Pam is currently developing an online Exam Review course for AAPC’s new Certified Inpatient Coder (CIC) and Certified Outpatient Coder (COC) credentials.Contact Pam at phaney@LibmanEducation.com.
Pam Haney

About Has 6 Posts

Pam Haney, MS, RHIA, COC, CIC, CCS, is Director of Training and Education for Libman Education and is responsible for online and instructor-led courses in medical record coding. Pam is currently developing an online Exam Review course for AAPC’s new Certified Inpatient Coder (CIC) and Certified Outpatient Coder (COC) credentials. Contact Pam at phaney@LibmanEducation.com.

3 Responses to “Accurate Documentation is Essential – Knowing When to Query your Providers”

  1. vickie houston-wilkerson says:

    Hello Pam, your information on queries was very helpful and easy to understand. I’m scheduled to take the CIC exam Oct 24th. I’m using the AAPC CIC study guide, which seems to be a great resource so far.

  2. Jacqueline Belinfanti says:

    I am interested in Clinical Documentation for Out & InPatient Medical Records

  3. Regina Carter says:

    Hello,
    I have a question. I work at a free standing Radiology Facility as a Medical Coder and we have been getting orders from referring physicians with the ICD-10 Code as the diagnosis. Not necessarily the description of the diagnosis but the actual Diagnosis Code. I was under the impression that the history on an exam or reason for visit must be written and that we shouldn’t be receiving just the ICD-10 Code because how do I know if the Code sent is correct if they are only sending the ICD-10 Code as the reason for exam. I hear that one of our surrounding hospitals is requesting that referring physicians give them the ICD-10 Code instead of the Description of why the patient is having a particular exam ordered. What is your take on this?

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