Accurate Documentation is Essential – Knowing When to Query your Providers

Yes, we know that ICD-10 is finally a reality, but by now coders should be starting to get into the groove. We (coders) have – hopefully at this point – learned to code diagnoses with ICD-10-CM, have gotten used to the root operations in ICD-10-PCS, and have been putting our new skills to work!

The other day I was talking to someone about query’s – and our discussion made me decide to write a short blog post about it.

To identify the correct ICD-10 codes, coders must identify conditions that require clinical evaluation, therapeutic treatment, further diagnostic studies, procedures or consultation, extending the patient’s length of stay or increasing nursing care and/or monitoring of the patient.

In short – a well-designed query is very important for successful coding!! Here are some query guidelines for you to keep in mind:

– The condition or diagnosis must already be established in the medical record
– The query should simply state the facts
– Queries should not lead the provider to a specific diagnosis
– All payer types should be queried, not just those that have an impact on reimbursement

Okay – so now that you’ve know those things what about when knowing when coders should query the provider? Here are a few key questions to ask that may help you determine if a query should be initiated:

1. Is there incomplete information in the medical record such as missing test results, progress notes or discharge summary?
2. Is there conflicting information in the medical record? Sometimes documentation in the progress notes may conflict with information in the discharge summary.
3. Are there any other reportable conditions or procedures that require more information to be coded?
4. Is there documentation of an unspecified diagnosis when clinical reports point to a specific diagnosis?

After all that I should mention that it is JUST as important to know when NOT to query providers. A good thing to keep at the back of your mind is that queries should not question a provider’s clinical judgment, when the benefit is strictly for reimbursement, or for clinically insignificant findings or irrelevant information.

Queries are an essential communication tool for accurate documentation and quality coding. They should be fact-based to clarify documentation and improve data integrity. Designing a solid query process will help support providers to continually improve their documentation for ICD-10 success.

Now – I should end with a little bit of a plug, as usual. Since you’ve made it to our blog you know that Park Medical Billing is a remote billing and coding company that has staff that are highly trained and 100% dedicated to making sure that you get maximum reimbursement for all your claims. If you haven’t considered outsourcing your medical billing maybe it’s time! Please give us a call to set up a free demo or you can also send us a message through our contact page.

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