Physician query examples 2025

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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.
An example of a leading query would be, This patient is bedbound and needs assistance in all activities of daily living. Wouldnt you characterize him as having functional quadriplegia? The CDIS is putting words in the physicians mouth.
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.
Never tell the physician what to write, no matter how clear the clinical picture appears. Be sure to ask clear questions and always provide the physicians with multiple answer options and always include an out such as unable to be determined. This will aid in the query being compliant. Avoid Yes/No questions.
The question asked in a physician query may be the most important element of the document. 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.

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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.

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