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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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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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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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,...
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Beth Martilik, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador “A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or...
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Most queries are written to clarify documentation as it relates to reimbursement. However, code assignment not only impacts reimbursement, but also other significant uses of coded data. Ideally, queries would be written as necessary to ensure data integrity and full and complete documentation.
read more 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.
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.
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.
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.
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,...