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What is a physician query for conflicting documentation?

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.

What is a query in medical terms?

A query is 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. Synonymous terms for query include: clarification, clinical clarification, and documentation clarification.

How do I create 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 do you write a compliant physician query?

AHIMA Query Guidelines Queries should include multiple choices for physicians to answer. The query title should not contain leading or impactful information. Include a clear, concise, and non-leading query statement. The supporting evidence for clinical indicators must be specific to the patient and episode of care.

What is the purpose of a physician query?

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.

What is a query in medical terms?

A query is 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. Synonymous terms for query include: clarification, clinical clarification, and documentation clarification.

How do I create 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.

What is a physician query form?

A physician query is a request made by a coder for additional information from the physician. This additional information is then used to determine the best way of coding the clinical services provided for insurance purposes.

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