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From Coder to Colleague through Querying

From Coder to Colleague through Querying

With a little encouragement, you can rise to challenges and become the “go-to” person.

If you answer yes to any of these questions, you need some professional encouragement:
Do you sometimes think you will be where you are in your coding career forever? 
Do you feel unheard or disregarded by your providers?
Are you too intimidated to query your providers?
Encouragement can make something more appealing or more likely to happen, or it can make someone more determined, hopeful, or confident. I want to encourage you.
Let’s explore the above questions and brainstorm solutions that will make your work more appealing; help you to be more determined, hopeful, and confident; and empower you to take action — all of which will lead to greater satisfaction in your career.

Move Up the Ranks

Do you sometimes think you will remain where you are in your coding career forever?
It’s important to get up every morning excited about the challenges ahead in your current role. If you feel stuck in your position, consider whether you’re taking steps to change where you are.
Opportunity often comes knocking disguised as challenge. To see if you are rising to career challenges presented to you, ask yourself:
Am I learning new things every day as I search for solutions to coding conundrums? 
Do I share what I learn with fellow coders and my providers? 
Am I positioning myself to be the coding expert in my office, specialty, or coding group? 
Have I stepped up to serve as a local chapter officer?
Accomplishing one or more of these things could help move your career forward. Attitude can lead to altitude.

Arm Yourself with Knowledge and Speak Up

Do you feel unheard or disregarded by your providers?
You may  lack confidence to speak up and engage your providers because you think you aren’t knowledgeable enough.
Knowledge is power. You can empower yourself as you discover answers to questions that you encounter each day. Research, study, gather information, and create an arsenal of conundrums paired with solutions found in source documents and references.
Learn the CPT® rules and documentation guidelines well enough to explain what quantifies a particular level of service to a provider. Know the ICD-10-CM guidelines so well that you can identify an error or omission, and know when and what to query.

Query Providers

Are you too intimidated to query your providers?
Don’t be intimidated. When you run into a circumstance where you cannot correctly code from the written documentation, you must query. Practice “authoritative” query, which is to justify your query and educate the provider using the guidelines they are held to in audit. It becomes an educational opportunity for the provider and raises your standing in the provider’s eyes. Plus, you are giving the provider something of value: You are helping to increase the likelihood of correct coding (that leads to proper payment) and possibly preventing future queries regarding that issue.
The ICD-10-CM Official Guidelines for Coding and Reporting instruct the coder to query the provider in certain circumstances. These guidelines are not just recommendations; they are requirements acknowledged under federal law. Per the introduction of the Official Guidelines, “Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).”
Note: This article focuses on ICD-10-CM coding queries. We’ll consider CPT® coding queries in a future issue of Healthcare Business Monthly.

Know When to Query

Choose what to query carefully and thoughtfully. If an official guideline pertains, query. If it makes a difference to the portrayal of medical necessity on the claim form, query. It could mean the difference between payment and denial.
Here are some examples of when the ICD-10-CM Official Guidelines for Coding and Reporting instruct coders to query:
When coding complications of care (section I.B.16):

  • “Query the provider for clarification, if the complication is not clearly documented.”

When a provider uses the term “borderline” (section I.B.17):

  • “Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.”

When coding acute organ failure and sepsis and severe sepsis (sections I.C.1.d.1.a.iv and I.C.d.1.b):

  • “If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.”
  • “Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.”

When coding acute respiratory failure (section I.C.10.b.3):

  • “If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.”

When coding ventilator-associated pneumonia (section I.C.10.d.1):

  • “If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.”

When coding pressure ulcers (section I.C.12.a.5):

  • “If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.”

When coding acute traumatic versus chronic or recurrent musculoskeletal conditions (section I.C.13.b):

  • “If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.”

When coding complication of kidney transplant (sections I.C.14.a.2 and I.C.19.g.3.b):

  • “If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.”

When coding conditions present on admission (Appendix I):

  • “If at the time of code assignment the documentation is unclear as to whether a condition was present on admission or not, it is appropriate to query the provider for clarification.”
  • “Coders are encouraged to query the providers when the documentation is unclear.”

You should also query when you see an error or omission in the provider’s assignment of ICD-10-CM codes into the assessment in the electronic health record (EHR).
Error Example: The provider codes both the definitive diagnosis and the associated signs and symptoms (section IV.D).
Error Example: An outpatient provider populates the code for a definitive diagnosis, yet in the freeform field, she types language such as, “probable,” “suspected,” “rule out,” or lists differential diagnoses (e.g., this vs. this vs. this). A coder who understands the guideline (section IV.H.) is able to recognize the provider has coded incorrectly.
Omission Example: You see a code populated into the assessment whose descriptor ends “in diseases classified elsewhere” without another code first. You know the provider missed the instruction to “code first underlying disease,” or “code first underlying condition,” or “code first underlying disorder” because the instruction is in the Tabular List and many EHR systems are void of the guidelines and instructional notes.
A thorough understanding of the guidelines and instructional notes will help you identify errors and omissions and know when to query. Provide value with every query; the best way to do that is to copy and paste the pertinent guideline(s) or instructional note(s) into your query. This will educate your provider, which will reduce the number of future errors and omissions.
Remember: Correct coding — coding that is both accurate and complete (right code, right number of codes, and right order of codes) — is intended, according to the ICD-10-CM Official Guidelines for Coding and Reporting, to be a “joint effort between the healthcare provider and the coder … to achieve complete and accurate documentation, code assignment, and reporting of diagnoses …”

Consider Yourself a Colleague

Be excited about the coding challenges you encounter. See them as opportunities to grow, learn, and shine. Have greater confidence in your provider interactions knowing you are officially instructed to query them and have the authority to do so. I hope I’ve encouraged you to be more determined than ever to grow personally and professionally, and to have the confidence to take positive action to move from coder to colleague.

Linda R. Farrington, CPC, CPMA, CPC-I, CRC, is an ICD-10-CM Trainer, senior provider training and development consultant at Optum, and owner and instructor of Medisense “Making Sense of Medical Coding” ( She has over 30 years’ experience in healthcare, specializing in cardiovascular thoracic surgery and risk adjustment. Farrington has written articles; presented audio conferences, workshops, and trainings; and served on the AAPC National Advisory Board from 2007-2011. She has served in various leadership roles for the Phoenix, Ariz., and Colorado Springs, Colo., local chapters.

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