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But heres AHIMAs example of a leading query: Is the patients pneumonia due to aspiration? Such queries can get a hospital in trouble.
But heres AHIMAs example of a leading query: Is the patients pneumonia due to aspiration? Such queries can get a hospital in trouble.
Queries should not be done to question a providers clinical judgement, only to clarify the documentation. Leading queries that tend to lead the provider in a certain response could be considered as inappropriate upcoding.
Compliant query practice should follow these tenets: Queries must be accompanied by clinical indicator(s) that: Are specific to the patient and episode of care. Support why a more complete or accurate diagnosis or procedure is sought. Support why a diagnosis requires additional clinical support to be reportable.
A physician query is defined as a written question to a physician to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patients health record.
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A physician query is a request made by a coder for additional information from the physician. Theyre typically used to determine the best way of coding some nuanced aspect of clinical care for insurance purposes, which can sometimes lead to friction between clinicians and the medical coders if mismanaged.
Following are some tips to help you write effective, compliant queries: Queries are not the time to educate physicians about coding. Have clear titles. Make sure your question is clear. Offer response options. Avoid Yes/No questions. Quote the medical record word-for-word. Never introduce new information.
Following are some tips to help you write effective, compliant queries: Queries are not the time to educate physicians about coding. Have clear titles. Make sure your question is clear. Offer response options. Avoid Yes/No questions. Quote the medical record word-for-word. Never introduce new information.
Additionally, the query should present only the facts that identify why the clarification is needed. Physician queries should not steer the provider towards a specific diagnosis or procedure. They should also never indicate the impact on reimbursement, payment methodology, or quality metrics.
What is a Physician Query? The American Health Information Management Association (AHIMA) defines a physician query as a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment for an individual encounter in any healthcare setting.

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