Query Tip: Is Sepsis Present on Admission?

In addition to positive clinical indicators documented at the time of admission, any of these that occur within the few days after admission should also be included. This will support the fact that sepsis could have developed after admission. It is important that a POA query give equal attention to what supports POA yes, as well as POA no to avoid the appearance of a leading query.

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Query Tip: Query Question is Key

The key to a quality physician query is the question. The question provides direction for the choice of clinical indicators and options for response. So why do so many coders have trouble writing the question? My theory is that coders overthink the question rather than keeping it simple and to the point. The best way to get a physician to answer a query is with a question that makes sense and eliminates guessing as to what is being asked.

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

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.

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