General Surgery Coding Alert

When querying the practitioner, be aware not only of your tone, but of their time.

When it comes to communication, tone is everything. Think about how much can be misinterpreted in a text message versus a face-to-face discussion — this is the nature of querying the practitioner. This is why it is so important to keep your tone respectful and personable. Understanding that you both bring different but necessary skill sets to the table to make one winning team will make all the difference in the success of your future queries.

Keep reading to learn more about how to make your queries lead to the information you need the first time around.

See the Reasons for Querying

You may find yourself querying your provider for one or more of the reasons below:

• Lack of legibility: If you are unable to read the information given to you, you will need to query the provider.
• Incomplete information: Occasionally, you may encounter clinical indicators like diagnostic labs, imaging, pathology, or prescribed medications within the patient’s medical record. If these or other aspects of medical care aren’t documented by the provider, it’s important to initiate a query.
• A need for clarity: If your practitioner has listed signs and symptoms in the medical record, but failed to mention a definitive condition or diagnosis, this would be a reason to query.
• Lack of consistency: There should be consistency within the medical record. If there are any inconsistencies in the notes from the beginning to the end of the encounter, you need to query.
• A need for more precision: To assign ICD-10-CM codes to the highest level of specificity, you must have matching and supporting documentation. If you don’t feel the practitioner’s notes deliver this, query them.

When it comes time to query the practitioner, be aware not only of your tone, but of their time. Keeping your queries concise will be the key to getting your information in one go, instead of having multiple discussions or sending multiple emails.

Defer to CMS Guidelines to Avoid Recoupment

To avoid a claim being denied or funds being recouped, keep in mind that the Centers for Medicare & Medicaid Services (CMS) stress that for a claim to be valid, there must be sufficient documentation to verify services performed were “reasonable and necessary” and “supports the level of service” billed. This means that if any necessary documentation is missing or insufficient, then there is no proof the reported codes accurately represent the encounter and this would be considered an overpayment, resulting in a recoupment of funds.

CMS dictates medical record notes should meet the following criteria:

1. Notes are complete and legible.
2. Notes should include:
   • The reason for the patient encounter, any relevant history, findings, diagnostic test results, and the date of service;
   • The patient assessment, clinical impression, or diagnosis that was reached;
   • The plan of care; and
   • The date of service and legible identity of the observer.
3. The reasoning behind ordering diagnostic and additional ancillary services should be readily deducible, even if it’s not explicitly documented.
4. Past and present diagnoses are available to the treating and/or consulting physician.
5. Appropriate health risk factors are readily identified.
6. The patient’s progress, response to and changes in treatment, and/or revision of diagnosis are all documented.
7. The treatment and diagnosis codes (as well as the level of care) being reported are supported by the documentation.

You can find more information regarding what CMS deems necessary in their Medicare Learning Network (MLN) Evaluation and Management Services Booklet.

Look at This Quick Query Reminder Checklist

Let’s quickly review the do’s and don’ts of querying the practitioner.

Queries should:

• Be clear and concise
• Contain simple and direct language
• Itemize the clinical indicators or clues from the health record
• Contain all the patient’s identifying information such as name and date of service, as well as clinical findings with supporting documentation that results in a specific question for the provider
• Leave queries open-ended and refrain from leading the practitioner with the language you use
• Follow the same format every time

Queries should not:

• Question a provider’s clinical judgment
• Lead the provider to answer in a certain way
• Include the impact on revenue

Present Your Query Effectively

Whether you present your query while the patient is still under treatment (concurrently) or after the encounter (retrospectively), all queries should follow the same format, regardless of how they are delivered to the provider. Creating a cut-and-paste template is a great way to keep everything uniform for every query. Taking the extra step to be sure those templates are compliant with your practice’s policies is even better.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC