Query Tip: Bullet vs Paragraph: What Format is Best for Clinical Indicators?

by | May 25, 2018 | 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

The ultimate goal of a physician query is to obtain clarity to physician documentation in the patient’s health record. In order to accomplish this goal, the coder must make the query as concise and easy to read as possible. If the physician has to take his/her valuable time to try and decipher what is being asked, there is a high likelihood that the response will be inadequate, if the query is answered at all.

Consider these clinical indicators for a query about a possible diagnosis of acute respiratory failure:

Patient was admitted 12/26 with acute COPD exacerbation due to acute bronchitis. The ER report notes shortness of breath, diffuse expiratory wheezing bilaterally with prolonged expiratory phase. Patient is tachypneic at 38 with O2 sats 60% on room air. There was use of accessory muscles. Patient was placed on 15L of supplemental oxygen with improvement in O2 sats to 96%. Patient received 3 nebulizer treatments, as well as 125 mg of IV methylprednisolone. Patient was also treated with ceftriaxone and azithromycin for possible bacterial bronchitis. Supplemental oxygen was reduced to 5L with maintenance of O2 sats above 90%. By 12/29 patient was on room air. Progress note on 12/27 indicates acute hypoxic respiratory distress on admission.

While there are obvious clinical indicators that will support the query, many physicians will find the paragraph format to be hard to read. Readers may tend to scan the information rather than taking note of the main points.

Now take a look at this alternative bullet format:

*Tachypneic at 38 with use of accessory muscles (ER 12/26)
*O2 sats 60% on room air (ER 12/26)
*Placed on 15L supplemental oxygen, sats improved to 96% (ER 12/26)
*Remained on 5L supplemental oxygen with sats above 90% until 12/29 (DS 1/2)
*Acute hypoxic respiratory distress on admission (PN 12/27)

The reader’s eyes will be drawn to the main points when listed in a bullet format. All unnecessary verbiage is eliminated, leaving just the pertinent clinical indicators supporting a possible diagnosis of acute respiratory failure.

There is no definitive rule or guidance about the format of the clinical indicators used in a query. Even AHIMA has used a paragraph format in query-related practice briefs. But it is my experience that the easier a coder can make the query process for a physician, the more likely a good outcome is realized. The KISS method works well in query writing!

 

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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