Sunday, June 21, 2015

Physician Query Process: Part 5: Format of a Physician Query, Developing the Statement at Issue, and the Importance of Hospital Policies and Procedures Related to the Physician Query Process

This is part 5 of the 11 part series from Barry Libman, Inc.    I've reposted here, GREAT INFO

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

How to format your query
All physician queries should be structured in a consistent manner. At a minimum, include:

  • Patient name
  • Admission and/or discharge date/date of service
  • Medical record number/Account number
  • Date of the query
  • Name/contact information of coder or person raising the issue/concern.

You then formulate and state the issue you need documented.

How to develop the statement of the issue at the heart of the query:
presented as a question

  • Must include factual clinical indicators from the chart and must ask the physician to make a clinical interpretation of those facts
  • The query format should not sounAll physician queries should contain elements of the following:
  • Must be d presumptive, directing, prodding, probing or as though the clinician is being led to a diagnosis
  • AND – must instruct the physician where to document the clarification resulting from the query.

The importance of an organization’s physician query policy and procedures

The hospital needs to have good policies and procedures that it can follow when it comes to the use of physician queries. Organizational policy and procedures should address:

  • Consistency of the query format
  • Frequency and appropriateness (query fatigue)
  • Templates
  • Insuring compliance and addressing non-compliance
  • Policy maintenance
  • More important than anything else – the policy must address whether the physical query form becomes a permanent part of the medical record or whether the physicians are required to clarify the query answer in a progress note or somewhere as an addendum.

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