Friday, May 22, 2015

Physician Query Process: Part 3: Appropriate Use Of Yes/No Physician Queries

**This is part 3 of an 11 part series from Libman Education.  This is good information.  More Information on the query process can be found at

Physician Query Process: Part 3: Appropriate Use Of Yes/No Physician Queries

Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.

As part of a continuing series of discussions relevant to the coding community, Libman Education presents this 11-part series on the importance of a well implemented physician query process.

Specific instances where Yes/No queries are acceptable, but in general, queries should not be designed to ask questions that result in a Yes/No response.  Like everything in life, there are exceptions.

1. Exception: POA queries when a diagnosis has already been documented.
Was the pressure ulcer POA?  Yes/No

2. Substantiating or further specifying “a diagnosis that is already present in the record”
Is this patient’s diabetes insulin dependent?  Yes/No

3. Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications and conditions/diagnostic findings
Is there a cause and effect relationship between the patient hypertension and their heart failure?  Yes/No

4. To resolve conflicting practitioner documentation
A consultant states the patient’s BMI is 30 but the dietician states it is 41.7.
Is the dietician’s calculation correct?  Yes/No

Anytime you are presenting a physician with a Yes/No type query, always offer an “other” option for uncertain/unclear and to create a space for the physician to leave a comment.

Next: Dealing With Legibility Issues And Challenging Handwriting?

For more information contact:
Christopher G. Richards, RHIA, CCS
Senior Associate, Barry Libman, Inc.

No comments:

Post a Comment