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.
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.
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.
One way a physician query would be considered leading is by the introduction of a new diagnosis in the query. This creates a difficult situation for a coder when the clinical information in the record supports a specific diagnosis, but the physician fails to give the diagnosis. How is a coder to write a nonleading query in this situation?