Query Tip: Avoid Repetition in Clinical Indicators

by | Jan 25, 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

Nothing is more likely to prevent a query from being answered than one that is too long. Are there any physicians that want to wade through a page (or more) of clinical indicator verbiage before getting to the actual question from the coder?

One way to shorten a lengthy query is by avoiding repetition in the supporting documentation. Does the same diagnosis really need to be mentioned multiple times in the clinical indicators?  Is it necessary to list the results of a chest x-ray twice? Does listing the same documentation multiple times give further specification or explanation to the query?

The clinical indicators should be a summary of the main points that support the query. Once the coder documents findings from the record in the query, there is usually no need to repeat it again.

Below is an example of what repetition looks like and how a query can be made more concise.

Repetitious

PN 12/30 – Possible Aspiration PNA, will switch ABX to IV Zosyn due to possible aspiration pneumonia.
PN 01/01 – Aspiration PNA on IV antibiotics
Consult 1/1/ – IV antibiotics
Sputum Culture – Organism: Staphylococcus Aureus

Can you identify the specific organism causing the patient’s pneumonia?

Concise

PN 01/01 – Aspiration PNA on IV Zosyn
Sputum Culture – Organism: Staphylococcus Aureus

Can you identify the specific organism causing the patient’s pneumonia?

 

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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