Query Tip: How to Be More Efficient

by | Jul 26, 2019 | Beth Martilik, Education, Query Tip | 0 comments

Beth Martilik​, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador Beth Martilik,​ MA, RHIA, CDIP, CCS
Assistant Director of Education
AHIMA Approved ICD‑10 Trainer and Ambassador

One of the reasons coders give to explain lower productivity is that queries are so time-consuming to write. Many coders will indicate the need to basically reread the record to find clinical indicators to support the question they need to ask the physician. This assumes the coder even remembers what needs to be queried after reading a 30 day stay! If coders wait until they review the record completely before recognizing the need to query, the result will be unnecessary “retouching the record” and wasted productivity.

The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query. However, if the physician fails to clarify the issue being questioned, the coder faces the need to come up with the clinical indicators to complete the query. If no notes are made along the way, the coder is left struggling to identify supporting documentation and its location in the record. If the coder has a long stay record, that task can be very daunting and time-consuming.

It is imperative that coders not only identify a potential query as soon as possible in the coding process, but to make key notations along the way to support it. This may seem like a lot of work for nothing if at the end a query is not needed. But, conversely, it could save a tremendous amount of time if a query is deemed necessary.

 

The information contained in this query advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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