Question

When documentation deficiencies are identified, educate the physicians on improving their documentation. Emphasize the initial importance of documentation by showing examples of how poor documentation can lead to adverse consequences. When clarification or additional information is obtained from the physician for coding purposes, make sure this information is subsequently documented in the medical record. Most coders are familiar with the coding principle of "query the physician" when documentation affecting code assignment is unclear or incomplete. Too often, the physician answers the coder's query verbally (or via a note) and the code is assigned based on this exchange, but the physician never adds the information to the record. Thus, the medical record documentation does not support the code assignment. It is not going to help a fraud investigation to tell an investigator "I asked the physician if it was okay to add a code for that condition, and he approved it." The condition must be documented in the medical record. Please discuss the following: As a coder what would you do to avoid this situation?

Answer 1

Query it is nothing but a question that is posed to a provider for clarifying documentation to improve the specificity and completeness of the data to an assigned diagnosis and procedures codes in patient's health care records.

A complete medical record should have following qualities:-

• Complete
• Precise
• Clear
• Consistent
• Legal

To avoid above mentioned situation the following things to be done :-

• Awareness and education to the physician should be given for example

1. Why queries are used
2. How to outline the situation
3. Providing him some examples of how to solve the queries in daily life situations that he faces
4. Emphasis on improving proper documentation and how queries can be a learning tool to the physician

• Perform audits
• Track and trend the findings related to physician queries
• Annual review of quality form and policies
• Solicit feedback .