Query Tip: Be Careful Using Yes/No Query Format
Until recent years queries were not designed for questions that could be responded to in a yes/no fashion. Open-ended or multiple choice formats were generally accepted. In a February 2013 Practice Brief (updated 2016) titled “Guidelines for Achieving a Compliant Query Process,” AHIMA introduced the Yes/No query format.
Queries in a Yes/No format are limited to use in the four specific circumstances listed below. This format may not be used when only clinical indicators of a condition are present, but the diagnosis has not been documented in the health record.
- Present on admission determination
- Substantiating or further specifying a diagnosis that is already present in the health record with interpretation by a physician (i.e. findings in pathology, radiology, and other diagnostic report)
- Establishing a cause and effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings
- Resolving conflicting documentation from multiple practitioners
Yes/No queries would still contain clinical indicators that support the question being asked. The difference between this format and others commonly used would be in how the question is asked and the options listed for physician response.
The physician gives a final diagnosis of abdominal mass, but the pathology report indicates a finding of adenocarcinoma of the sigmoid colon. A query is necessary to confirm the etiology of the mass.
Question: Do you agree with the pathology report that the etiology of the abdominal mass is adenocarcinoma of the sigmoid colon?
Options for response:
- Unable to determine
Patient develops an abscess at the incision site of a recent hysterectomy. A query is necessary to establish a cause and effect relationship between the abscess and surgery.
Question: Is the abscess a complication related to the recent hysterectomy?
Options for response:
- Unable to determine
A limitation of the Yes/No query format is that it may leave the physician response open to interpretation. By not having the response specifically spelled out, the coder will have to carefully design the question to avoid misinterpretation. All it takes is a question that is not specific enough to make the response questionable and may lead to the need to requery for clarification.
The surgeon creates several serosal tears of the bowel during a tedious lysis of adhesions. These are repaired with simple sutures. A query is necessary to establish a cause and effect relationship that may represent a complication.
Question: Are the serosal tears of the bowel related to the lysis of adhesions?
With this question and response, the coder is left wondering if the serosal tears are a true complication of the surgery, or an incidental occurrence that would not be coded as a complication. It may be advisable in this situation to use a multiple choice format to differentiate between complication versus no complication. Another option is to reword the question: “Are the serosal tears considered a clinically significant complication of the lysis of adhesions?”
Coders will have to be careful in the use of the Yes/No query format and to make sure it is only used in the specified scenarios. It is up to the coder to determine which format – open ended, multiple choice or Yes/No fits his/her needs and preferences. Each format has limitations, but give the coder options to achieve the goal of complete and accurate documentation in the health record.
As with any query, the physician response needs to be included in the medical record. This may be in the form of the actual query form or as written documentation in the record.
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.
Last week, we looked at tidbits for reporting the ICD-10-CM codes for pregnancy/obstetric records. Now we will look at some for the ICD-10-PCS reporting of these records. In reporting the appropriate ICD-10-PCS codes a coder must know what is included in the terminology of products of conception (POC).
Chances are, we all know someone affected by heart disease and stroke, because about 2,300 Americans die of cardiovascular disease each day, an average of 1 death every 38 seconds. But together we can change that.
There was a time when coding delivery records was considered simple. Many times, these types of records were given to the newer coders. However, as coding becomes more complex, this is no longer the case. With the implementation of ICD-10-CM came more codes for very detailed and specific issues that occur during pregnancy, childbirth and the puerperium.
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Allison Curry, RHIT, CCS, Coding Specialist at Health Information Associates, about the steps she takes to find her routine.
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?
Tobacco use can lead to tobacco/nicotine dependence and serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, but there are helpful treatments and resources for quitting.
This is Part 5 of a five part series on the new 2019 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
This is Part 4 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY 2019 and include examples to help the coder understand the new codes. There is 1 new lymphatic code, 2 new digestive system codes with 3 deletions, 3 new urinary system codes with one deletion and 7 deleted nervous system codes with 2 revisions.
This is Part 3 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There are 9 new cardiovascular CPT codes added with 2 deletions and 3 revisions.
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Tilina Sablan, RHIT, CCS, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
This is Part 2 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There are 4 new musculoskeletal CPT codes added with 2 deletions and 0 revisions.
This is Part 1 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There were 15 new integumentary CPT codes added with 3 deletions and 1 revision.
In part 5 of our series, we look at DRG 64—Intracranial hemorrhage or cerebral infarction with MCC. For this DRG recommendation the majority (almost all) were recommended to DRG 65 (Intracranial hemorrhage or cerebral infarction with CC) with deletion of the reported MCC.
The majority of the recommendations from DRG 190 (Chronic obstructive pulmonary disease w/MCC) was to DRG 189 (Pulmonary edema and respiratory failure) with re-sequencing of respiratory failure as the PDX or adding as a new code and sequenced as PDX.
The majority of the recommendations from DRG 853 (Infectious & parasitic disease with O.R. procedure with MCC) were to DRG 871 (Septicemia w/o MV 96+ hours with MCC) with deletion or revision of the PCS code. Some of these required physician query.
The majority of the recommendations from DRG 872 (Septicemia w/o mechanical ventilation 96+ hours w/o MCC) were to DRG 871 (Septicemia w/o mechanical ventilation 96+ hours with MCC) with the addition of an MCC to the account. Not all of these required a physician query and were present in the medical record documentation without any clarification needed prior to coding.
The majority of the recommendations from DRG 871 (Septicemia w/o MV 96+ hours with MCC) were to DRG 872 (Septicemia w/o MV 96+ hours w/o MCC) with the recommendation to delete the reported MCC or query for clarification to support the MCC that had been reported.
Every year, we make plans to live a healthier, more organized, and balanced life. For some of us, we end up falling short of those expectations. This year, to keep us on track with our New Year’s goals, we have put together a few of the most common New Year’s resolutions along with their ICD-10 diagnoses codes. Check out our tips and tricks for a healthy 2019!
Top 5 ProFee diagnosis changes found in recent HIA reviews: 1. I10 – Essential (Primary) Hypertension; 2. E11.9 – Type 2 Diabetes Mellitus Without Complications; 3. K29.60 – Other Gastritis Without Bleeding; 4. R13.19 – Other Dysphagia; 5. I25.10 – Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris.
What is the principal procedure? The procedure that is performed for definitive treatment or is taking care of a complication is the principal procedure. Procedures for diagnostic or exploratory purposes that are performed in addition to a procedure being performed for definitive treatment, would be reported in addition to the principal procedure.
A query question that is directive in nature, indicating what the provider should document, rather than asking for his/her professional determination of clinical facts, constitutes a leading query. The provider should not be made to feel obligated to document anything.
When I start coding a chart, I enter all account information in log and do any abstracting—disposition, admitting, and attending—take care of all of that first. ED, H&P, consult, progress reports, and discharge summary.
Some Speed Reading Tips: Once you start reading, don’t stop! Read the text straight through. If you have any question after you have completed reading the material, go back and reread the relevant sections. Reread the marked sections of the text (the items you indicated that you didn’t quite understand). Write a small summary at the beginning of the chapter – consisting about 3-4 sentences.
In HIA quality reviews we are finding that some coders are reporting Z41.2—Encounter for routine and ritual circumcision, during the male newborn birth admission, when circumcision is performed prior to discharge.
The cause/etiology of GI bleeding is not always easily determined. During procedures, to work the bleeding up, there are often multiple potential sources of bleeding found but not identified as the culprit. Many of these findings have “with” or “in” in the main or subterms.
On December 1, 2018, the HIA team based at our headquarters in Pawleys Island, South Carolina received a visit from a surprise guest – meet Otis, HIA’s very own Elf on a Shelf. Otis will be sticking around until Christmas to keep an eye on all of us. We have a feeling he may get into some trouble! Check back daily to see what Otis is up to. #OtisOnOtisDrive
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our new series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Crystal Junkins, CCS, CPC, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
COPD is a respiratory condition where there is chronic obstruction to airflow in the lungs. Air is breathed into the lungs but a patient with COPD has trouble emptying air out of the lungs. This can also cause patients with COPD to have CO2 retention. COPD is an irreversible and progressive disease in which the lung function worsens as time goes on.
Tissue findings interpreted by a pathologist are not equivalent to the attending physician’s medical diagnosis based on the patient’s clinical condition. If the attending physician has not indicated the significance of an abnormal finding within a pathology report…