Query Tip: Choosing Reasonable Options for Response
Beth Martilik, MA, RHIA, CDIP, CCS
Assistant Director of Education
AHIMA Approved ICD‑10 Trainer and Ambassador
“Multiple choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record…” Guidelines for Achieving a Compliant Query Practice (2019)
The key to choosing reasonable options for a query response is to remember that the query must stand alone. Any clinical indicators supporting the options must be included in the query itself. Below are examples of two queries in which the options for response are not reasonable based on clinical indicators used by coder.
Example of Unreasonable Query Options:
| *SOB on admission with BNP 1100 and CXR showing CHF (H&P) *IV Lasix given x 2 days with improvement, continued home dose at discharge (DS) *Final diagnosis CHF exacerbation (DS) Can you clarify the type of CHF being treated? |
The type of CHF is based on evaluation of the right and left ventricular function. Tests that can show this include echocardiogram, MUGA scan, or cardiac catheterization. The measure of the left ventricle’s ability to pump (ejection fraction or EF) can be obtained from these tests. Therefore, a query for the specific type of CHF must include clinical indicators related to ventricular function, otherwise the options would not be reasonable. The coder could add the EF value, or any ventricular dysfunction as part of the clinical indicators. That would make these options for response reasonable and clinically supported.
Example of Unreasonable Query Options:
| *SOB and tachycardia on admission with H&H 5.6/20.4 (H&P) *PRBC x 2 with improvement (DS) Can you specify the type of anemia being treated? |
A reasonable option must be supported by whatever the coder uses as clinical indicators. There is nothing in this query to show that the patient had a history of blood loss. In fact, there is nothing in the clinical indicators to support any specific type of anemia. The coder should add documentation that refers to blood loss, either acute or chronic. If the coder feels the anemia may be related to something else, entries such as recent chemotherapy or malignancy, or use of iron supplementation may also be added. It is vital that any options for response are reasonable and clinically supported by documentation contained in the query itself.
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.
Popular Posts
Coder Q&A with Pat Mac: Collapse of an Endograft
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.
Find Your Routine: Be Flexible, Not Frustrated
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
Coding Tip: Periprosthetic Fracture Reporting and Sequencing
Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
OIG Takes Notice of Coding Errors
Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.
Coder Q&A with Pat Mac: Coding for Newborn
There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?
Subscribe to our weekly newsletter
Latest News
Coder Q&A with Pat Mac: Collapse of an Endograft
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.
Find Your Routine: Be Flexible, Not Frustrated
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
Coding Tip: Periprosthetic Fracture Reporting and Sequencing
Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
OIG Takes Notice of Coding Errors
Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.
Coder Q&A with Pat Mac: Coding for Newborn
There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?
Query Tip: When to Query for Sepsis
Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?
Coder Q&A with Pat Mac: Principal Dx Selection
In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?
Find Your Routine: Track Trends to Save Time
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Kerry Atkins, CDIP, CCS‑P, COC, CPC, CPCO, CPMA, CEMC, COBGC, RMB, Physician Services Consultant at HIA, about the steps she takes to find her routine.
Keeping a Healthy CMI
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Coding Tip: Spinal Procedures Reported in Addition to the Fusion
With the implementation of ICD-10-PCS more codes were developed in order to accurately report procedures. Spinal fusion coding is still a problematic coding issue and at times, even a coder’s nightmare. Coders often report only the code for the fusion thinking that one code would include all of the other procedures that are performed.
Coder Q&A with Pat Mac: Procedure Coding for a Breast Procedure
Answer: I would code 0HPT0NZ for removal of tissue expander from right breast, open and change 0HPT0JZ, removal of synthetic substitute from right breast, open, for removal of the acellular dermal matrix to 0HPT0KZ, Removal of nonautologous tissue substitute from right breast, open approach.
Coding Tip: “Code First” Instructional Notes in ICD-10-CM
There are certain conditions that have instructional notes in the ICD-10-CM tabular/coding conventions that guide the coder in sequencing. This is especially true when the condition has a common manifestation or underlying conditions of a chronic disease. If there is a “code first” note in the tabular, the coder should follow this instruction and sequence the underlying etiology or chronic condition first followed by the manifestation as an additional diagnosis.
Find Your Routine: Tools to Tackle Unpredictable Days
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 reviewers and asked them what steps they take to find a rhythm that works for them. This week, we talked with Meghan Schumacher, CPC, CPMA, Provider Coding Consultant at Health Information Associates, Inc., about the steps she takes to find her routine.
Time is Money
Last year, the Office of Inspector General (OIG) performed an investigation that found, “between 2014 and 2016, Medicare Advantage organizations overturned 75% of their preauthorization and payment denials upon appeal,” which is why, at HIA, we always advise our clients to engage in the appeals process.
Query Tip: Query for Acute Kidney Injury (AKI)
There may be instances where a coder will suspect the patient has acute kidney injury (AKI), but the physician has failed to document the diagnosis. In another scenario, the physician may have made the diagnosis, but there is a question of clinical validity. In either case, a query would be justified.
IPPS Proposed Rule: CC/MCC Designation Changes
Changes to CC/MCC designations included in the proposal could have a potentially dramatic effect on casemix. The presence of a major complication or comorbidity (MCC) or complication or comorbidity (CC) generally is representative of a patient that requires more resources.
It Only Takes One Code
How many times have you heard “it only takes one code to get the claim paid”? With the emphasis on the severity of illness and the move toward value-based reimbursement in today’s healthcare climate, it is more important than ever for coders to report all applicable diagnoses. There are three important pieces: what the provider documents, how to the coder interprets that documentation and codes it, and then how it is extrapolated.
How to Reduce Claims Denials
The reimbursement landscape is already a complicated one – and the highly-complex claims denials process only adds fuel to the fire. A denied claim is one that has been determined by a payor to be in appropriate. Once a coding specialist amends the errors on a rejected claim, they can resubmit it for consideration. The time-intensive process has a significant impact on the cash flow for any setting in the healthcare environment. They are also very costly to appeal.
Query Tip: Query for Clinical Validation
When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, a coder has four choices: (1) Code the diagnosis; (2) Ignore the diagnosis; (3) Generate a query to confirm clinical validation of a diagnosis; (4) Follow the facility’s escalation policy for clinical validation.
$30M Settlement for Medicare Advantage Upcoding
A California-based healthcare services provider and several of its affiliates have agreed to pay $30 million to resolve allegations they submitted inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans, according to the Department of Justice.
National Volunteer Week with HIA
Happy National Volunteer Week! This week we celebrate the impact volunteer work has on building stronger communities. We know that our staff have a positive impact while they’re on the job, and we are proud to share a few ways our #PeopleBehindTheNumbers are taking time to volunteer in their own local communities.
Challenges Facing ASCs in 2019
Scrutiny of coding compliance in the growing ambulatory surgical center (ASC) market has increased in recent years from both Medicare and private payers. This will only increase as the Centers for Medicare and Medicaid Services (CMS) moves towards value-based care.
Coding Tip: Acute Renal/Kidney Failure/Injury vs Dehydration as a Principal Diagnosis
Patients being admitted for acute renal failure due to dehydration have been happening for many, many years now. Typically what happens is a patient gets dehydrated for one reason or another. Once dehydration sets in, it can quickly start to affect many body organs. This can lead to acute renal/kidney failure/injury.
Find Your Routine: Don’t Leave Any Loose Ends
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 Zahra Ghahremani, CCS, Coding Specialist at Health Information Associates, about the steps she takes to find her routine.
Query Tip: Be Consistent with Query Format
All queries require at least two elements – clinical indicators and a query question. Coders can also include multiple choice options for response or leave the query open-ended for a free text response. The order in which these elements are listed in a query is open to coder or facility preference.
HIA Gives Back to St. Jude, ASPCA in 2018
Giving back is an important part of the HIA mission. Each year, HIA employees take a consensus and choose three National charities to support. Individuals can volunteer a portion of their wages to one of the three organizations. HIA Corporate will match each individual donation up to five dollars. We are proud to share with you our 2018 contribution totals combined with HIA matching funds.
Coding Tip: Unspecified Condition Codes and Combination Codes
One area that coders struggle with is when to report a separate condition code when an already assigned combination code includes the condition. For example, if an obstetric patient is admitted and delivers, and the physician documents “obstetric patient delivered with anemia,” should both code O99.02 Anemia complicating childbirth and D64.9, Anemia, unspecified be coded or should only O99.02 be assigned?
Find Your Routine: Set a Pattern, Follow it
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 Donna Cowan, RHIT, CCS, Coding Specialist at Health Information Associates, about the steps she takes to find her routine.
Coding Tip: Obstetric Tidbits for PCS
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).