Guidelines for Compliant Query
Leading query
one that is not supported by clinical elements in the health record and/or directs a provider to a specific dx or procedure
Query
A communication tool used to clarify documentation in the health record for accurate code assignment
If practitioner documents only on query form
query form should become part of the permanent health record
Multiple choice query
should include clinically significant and reasonable options may be only one reasonable option DO NOT introduce new information
Yes/No query
substanding or further specifying a dx that is already present in the health record establishing cause and effect relationship between documented conditions resolving conflicting documentation from multiple practitioners
"possible"
to broad term and its use in query is discourage
Intent of guidance
to maintain the integrity of the coded healthcare data
When to generate a query
when health record documentation: Conflicting Incomplete Imprecise Unclear Provides dx w/o underlying clinical validation Unclear POA indicator assignment
Proper query
ensures approptiate documentation appears in the health record
Personnel performing the query
focus on acompliant query and appropriate indicators to support the query
Verbal query
follow same format as written
Query process
ALL professionals must adhere
Relevant clinical indicators
All queries must be accompanied by it to show why a more complete or accurate dx or procedure is requested
Desired outcome
An update of health record to better reflect a practitioner's intent and clinical thought process, documented in a manner that supports accurate code assignment
Open-ended query Leading
Are you treating COPD?
Open-ended query Nonleading
Based on your clinical judgement, can you provide a dx that represents the below-listed clinical indicators?
Unanswered queries
CMS revommemds that each facility develop an escalation policy and address anx staff concerns regarding queries
Non-leading query
Can the etiology of the pt's pneumonia be further specified?
Multiple choice query Wordings
Clinically undetermined Other Allow the provider to add free text Not clinically significant Integral to
Query etiquette
Coders and clinical documentation can't lead healthcare providers with queries
Final code
Is the finsl code dx and procedures derived from the health record documentation should accurately reflect the pt's episode of care
Leading query Ex
Is the pt's pneumonia due to aspiration
Coding Clinic
Practiotioners DO NOT have to use the criteria outlining but readonable support within the health record for the dx must be present
Open-ended queries
Preferred
Verbal documentation
Verbal queries should be documented at the time of the discussion or immediately following
Do you agree?
Yes/No query Compliant
New dx
cannot be derived from yes/no query