Ob-Gyn Coding Alert

Having a good relationship with your provider is also essential. “If you can establish a relationship with your provider, you’ve done 75 percent of the work in coding and querying,” Emily Schmidt Barnette, CPC, CPC-P, CDEO, CPB, CPMA, CRC, CPC-I, said during the 2023 HEALTHCON presentation, “Communicating with Providers.”

Read on to learn more.

Consider These 5 Reasons to Query

You may need to query your provider for any of the reasons below:

• Legibility: If you as the coder cannot read and input the information, you will need to query.
• Completeness: At times, there may be clinical indicators such as diagnostic labs, imaging, pathology, or prescribed medications found within the patient’s medical record. If they, or other elements of medical care, are not documented by the provider, you should query.
• Clarity: Oftentimes, signs and symptoms may be reported or present in the medical record, but your provider hasn’t established a definitive condition, which could be a reason to query.
• Consistency: Consistency involves variances within the medical record. You need to query if there are any inconsistencies in the notes from the beginning to the end of the encounter.
• Precision: Although ICD-10 gave us an opportunity for increased specificity in code assignment, to assign codes to the highest level of specificity, we must have matching and supporting documentation.

Know How to Present a Query

Queries may be written or verbal and generated in one or both of the following ways:

• Concurrent (while the patient is still under treatment)
• Retrospective (post-encounter)

“The technique of writing a query is critical in ensuring clear and precise communication to a provider. Make sure that the question you are asking makes sense with the information you are providing as support. I like to use ‘specify and clarify’ in my queries, but any language will work provided the doctor understands the query,” says Vida Rothstein, RHIT, CCS, AAPC inpatient auditor for Audit Service Group from South Bend, Indiana.

All queries should then follow the same format whether they are written, emailed, or delivered over the phone, stressed Schmidt Barnette. They should:

• Be clear, concise, and non-leading;
• Contain simple and direct language;
• Itemize the clinical indicators or clues from the health record; and
• 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.

“It’s important to avoid leading the provider with your language. “You want to avoid saying things like, ‘Please document if you agree that the patient has _________,’ and instead ask questions that will help you narrow down the correct coding,” Schmidt Barnette suggested. You should ask more specific questions like, “Based on your clinical judgment, can you provide a diagnosis that represents the below-listed indicators?” to get to the correct diagnosis.

It’s essential to use compliant query templates for written and emailed queries, as Schmidt Barnette emphasized during the presentation. This ensures consistency and accuracy in documentation across the entire office.

Aim for Mutual Respect

It’s important to keep in mind that tone is so much of communication. “Always be respectful of their time and highlight the mutual benefits of coding correctly … and don’t lecture. Be personable, don’t be a coder, don’t be a robot who just spits out coding guidelines: it just makes the whole thing easier,” Schmidt Barnette said.

She reminded her audience that both the coder and the practitioner bring different skill sets to the table that are mutually dependent upon each other and stressed the importance of encouraging teamwork. Being open to listening, asking meaningful questions, and understanding the value of each other’s time is also key to successfully querying the practitioner.