Guidelines for Compliant Query

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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


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