by Dianna Foley, RHIA, CHPS, CCS, CDIP
- An operative report states the surgeon did a wedge resection of the right upper lobe via thoracoscopy. Do you need to query for Excision versus Resection?
- A cardiologist is consulted for a patient with atrial fibrillation. Multiple providers, including the attending, have documented atrial fibrillation. The cardiologist documents permanent atrial fibrillation. Do you need to query in order to code I48.21 instead of I48.91?
- A patient comes into the ER with tachypnea,
tachycardia, cyanosis of lips, labored breathing, and is nonresponsive to
bronchodilators. The patient is admitted
with a diagnosis of asthma. Is a query
needed here?
Queries are a useful tool for clinical documentation improvement specialists (CDIs) and coding professionals. They are needed when the documentation in the patient’s record is incomplete, illegible, inconsistent, imprecise, or unclear. When used appropriately they provide the clarity needed to complete the diagnosis and treatment picture for the patient.
It is imperative that anyone who is seeking clarification of the patient’s diagnosis or treatment utilize best practices for creating compliant queries. Obviously, one of the most important aspects of a provider query is that it does not lead the provider to a specific answer. Another factor for compliance is that the impact of the answer on reimbursement or quality metrics is not mentioned.
Several different formats can be used for a query, including multiple choice, free text, and yes/no. The format should be determined by the type of information that is needed. For example, if a coding professional is trying to establish the present on admission (POA) indicator for a catheter-associate urinary tract infection (CAUTI), then a yes/no format would be a good choice.
Looking back at the questions at the beginning of this blog, question 1 does not require a query. It is the responsibility of the coding professional to translate the terminology used by the provider to the correct ICD-10-PCS root operation which in this case would be Excision.
In question 2, again no query is needed. The documentation is not conflicting. The cardiologist has just provided greater specificity of the type of atrial fibrillation that the other physicians had already documented.
Question 3 will be answered in our upcoming webinar “The Compliant Query Process” where we will delve deeper into when and how to query in a compliant manner. We hope you will join us for that webinar.
**Updated query guidance will be forthcoming from AHIMA in the near future. Any substantive changes that impact the webinar and/or blog will be posted once the practice brief is finalized.
Purchase the webinar HERE.
About the Author
Dianna Foley, RHIA, CHPS, CCS, CDIP is
OHIMA's Education Coordinator. Dianna has been an HIM
professional for 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.
