Query Tip: How to Be More Efficient

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.

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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.

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