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. In this week’s Query Tip, we provide examples of two queries in which the options for response are not reasonable based on clinical indicators used by coder.
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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?
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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.
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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…
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Conflicting documentation occurs when health care providers call the same condition different things. When none of the documented conditions are clearly ruled out by the physician, coders may find it necessary to query for the most appropriate diagnosis.
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Queries in a Yes/No format are limited to use in the four specific circumstances. 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.
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Queries written in a multiple-choice format include a short list of options for physician response. These options must be relevant and supported by the clinical indicators included in the query.
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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.
read more 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. In this week’s Query Tip, we provide examples of two queries in which the options for response are not reasonable based on clinical indicators used by coder.
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?
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.
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…
Conflicting documentation occurs when health care providers call the same condition different things. When none of the documented conditions are clearly ruled out by the physician, coders may find it necessary to query for the most appropriate diagnosis.