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Click ‘Get Form’ to open the physician query template in the editor.
Begin by entering the date at the top of the form. This is essential for record-keeping.
Fill in the recipient's name, typically the physician being queried, in the designated space.
Provide your contact information by filling in your name and phone number under 'Coder’s Name' and 'Coder’s Phone #'.
Complete patient details including their name, admit date, discharge date, medical record number (MR#), and account number (Acct #).
In the section regarding diagnosis, specify where pneumonia is documented in the medical records.
Indicate any identified organisms from sputum cultures as requested. If applicable, document this information clearly.
Respond to the questions regarding organism identification by selecting 'Yes', 'No', or 'Unable to determine' and provide necessary signatures and dates.
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What is the most desirable format for a physician query?
Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking. That way the response will be as specific as possible and eliminate the need for an additional query.
What is an example of a physician query?
These queries seek to specify or confirm diagnoses that are not clearly documented but are supported by clinical indicators. Example: A patients symptoms and test results suggest sepsis, but the diagnosis is not explicitly stated, a query would seek to confirm this condition.
What is an example of an appropriate query physician?
Below are examples of typical query questions: Can you identify the specific organism responsible for patients pneumonia? CLINICAL FINDINGS WITHOUT DIAGNOSIS: Can you provide the condition described by the clinical indicators listed above?
How to write a physician query?
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.
How to properly query a physician?
Queries should focus on specific clinical indicators or diagnoses requiring clarification and include supporting evidence and other relevant information, such as lab results, imaging studies, and other clinical data.
A physician query is a request made by a coder for additional information from the physician.
What is the physician query process?
initiate queries as appropriate when documentation within the medical record fails to meet one of the following criteria: legibility, completeness, clarity, consistency, and/or precision. A query may be generated by a CDI Specialist or a Coder.
what is an example of an appropriate query
Managing an Effective Query Process
Note: This practice brief updates the 2001 practice brief Developing a Physician Query Process, with a continued focus on compliance. In todays changing
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