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Documentation:

Bolster Clinical Notes With This Query Insight

Published on Thu Sep 01, 2022

Utilize query guidelines to help with coding choices.

A patient’s medical record is a legal document that tells the story of why that patient is being seen by a provider. However, some provider documentation is incomplete and needs a follow-up to confirm any conflicting, contrasting, or ambiguous information in the medical record.

Learn how to use different query types to clarify the provider’s documentation.

Seek Clarification Through Queries

A patient’s medical record should show what tests were ordered, what tests were performed, and the provider’s thoughts as to what was wrong with the patient at the time of the encounter.

When information is unclear in medical documentation, you’ll query the provider to receive clarification. Some of the reasons why you’d query a provider include, but are not limited to:

  • Supporting the documentation of a medical diagnosis
  • Clarifying the reason for the patient’s admission or visit
  • Clarifying if a diagnosis is ruled in or ruled out
  • Establishing a diagnostic cause-and-effect relationship between medical conditions

“What my providers tell me all the time is they went to school to be clinicians. They went to school to take care of patients. They didn’t go to school to do documentation, and they certainly didn’t go to school to do coding,” said Melissa Kirshner, MPH, CPC, CRC, CDEO, CFPC, Approved Instructor, executive director at Olympia Medical LLC in Livonia, Michigan, during her session, “Compliant Provider Queries,” during AAPC’s DOCUCON 2022 conference.

Seeking clarification through a query helps you understand what the provider is attempting to tell you, so the clinical picture of the encounter and the patient’s condition are complete and accurate.

Important: Queries should be a part of the patient’s permanent medical record, and the answers to the queries help support your code assignments.

Allow Physicians to Use Their Judgment

When crafting your queries, you should take special precautions to ensure you’re not leading the provider to a specific diagnosis. “We can’t tell the provider what to document. We have to let the physician use their own clinical judgment,” Kirshner said.

Scenario: A patient was admitted after experiencing nausea and vomiting for three days. A chest X-ray showed the patient was suffering from pneumonia in the right lower lobe. The patient then received clindamycin.

In this scenario, you would need more information regarding the cause of the patient’s pneumonia to ensure you can assign an accurate ICD-10-CM diagnosis code to the report. Instead of asking if the pneumonia is due to aspiration (leading query), you could request the physician to specify the cause of the pneumonia (nonleading query).

Not All Queries Need to Be Asked in Writing

Verbal queries are an acceptable option for receiving clarification, but the guidelines for verbal queries are the same as written ones. “We have to present the details to the provider. We have to include all of that patient clinical information — all of those relevant facts, all of those clinical indicators that we see in the medical record,” Kirshner added. The clinical indicators must be relevant to the question that you’re asking.

Additionally, once you’ve received the clarification you need for your query, you should document the conversation you had with the provider and include it as part of the patient’s medical record.

Be Open to Your Provider’s Response

Creating open-ended queries can pose a challenge but offer the chance to receive plenty of information. “Open-ended queries allow us to gather all of those clinical indicators that may be present in the medical record and then ask about the relevance,” Kirshner said.

Scenario: A patient presented to your practice with pneumonia. The history and physical exam revealed a white blood count (WBC) of 14,000, respiratory rate of 24, 102°F temperature, heart rate of 120 BPM, and hypotension.

Since the patient was showing a high WBC, fever, low respiratory rate, and an elevated heart rate, there’s a possibility that they may have an infection in addition to the pneumonia. An open-ended query of “Please document the patient’s condition and causative organism, if known, in the medical record,” allows the physician to use their clinical judgment to make a determination on the patient’s condition.

Give the Provider Options to Answer Your Query

Multiple choice queries can be useful when faced with several diagnoses that are supported by the medical record. “There’s not a minimum number or a maximum number of diagnoses that you should include on that list, but you need to make sure that they’re all clinically viable,” Kirshner said.

You should also provide choices that allow the physician to state that the patient’s condition is undetermined at this time or the condition is another option that wasn’t thought of originally.

The last type of query that you can use to receive clarification are Yes/No queries. Yes/No queries can be used to:

  • Identify cause-and-effect relationships
  • Identify manifestation and cause
  • Clarify conditions and diagnostic findings
  • Look at conflicting documentation between providers

At the same time, Yes/No queries cannot be used to introduce a new diagnosis — you may only ask the provider questions related to the clinical indicators.

Do Yes/No queries fall under leading queries? “Asking for clarification is not leading. We’re giving the providers the options of what this would be and then letting them use their clinical knowledge to tell you ‘Yes, it is’ or ‘No, it’s not,’” Kirshner said.

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