Physician Query Process: Part 4: Dealing With Legibility Issues And Challenging Handwriting?

**This is part 4 of an 11 part series from Libman Education.  This is good information.  More Information on the query process can be found at AHIMA.org

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Physician Query Process: Part 4: Dealing With Legibility Issues And Challenging Handwriting?

by 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. 

We’ve all seen this:

Handwritten and illegible entries in the patient health record are an important consideration in the query process. It is important to decide when bad handwriting rises to the level of a physician query.

In general, if your inability to read certain documentation is clearly going to impact your ability to assign an accurate code, then you need to consider a query.

From a quality of care and risk management perspective, illegible entries can:

• Cause miscommunication among clinicians about the patient’s condition
• Result in improper care and cause serious patient injury
• Raise questions of legal viability
• Easily lead to poor data quality and incorrect reimbursement
• Cause data collection, billing and reporting errors

- See more at: http://www.libmaneducation.com/physician-query-process-part-4-dealing-with-legibility-issues-and-challenging-handwriting/#sthash.uUK5SUi1.dpuf 

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 AHIMA.org

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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

OTHER/COMMENT________________

2. Substantiating or further specifying “a diagnosis that is already present in the record”

Is this patient’s diabetes insulin dependent?  Yes/No

OTHER/COMMENT______­­­­­__________

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

OTHER/COMMENT________________

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

OTHER/COMMENT_________________

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.

crichards@barrylibmaninc.com

www.barrylibmaninc.com

- See more at: http://www.libmaneducation.com/physician-query-process-part-3-appropriate-use-of-yesno-physician-queries/#sthash.zu0tkQLR.dpuf

Physician Query Process: Part 2: Describe General Aspects Of A Compliant Physician Query –

**This is part 2 of an 11 part series from Libman Education.  This is good information.  More Information on the query process can be found at AHIMA.org

^^^^^^^^^^^^^^^^^^^^^^^^^^^

Physician Query Process: Part 2:  Describe General Aspects Of A Compliant Physician Query – 

by 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.

Here are some basic query guidelines:  Just like on Jeopardy, a query must BE IN THE FORM OF A QUESTION!

Physician queries should focus on conditions or diagnoses already established in the medical record. A query should not introduce NEW information or information from another admission. Your focus is on accurately coding the current admission.

Queries apply to ALL payer types regardless of the impact on reimbursement. The focus must be on the data quality with respect to accurate code assignment. Queries are NOT just for DRG assignment.
A compliant query should seek clarifications based on a statement of the facts found in the record that you as the coder turn into a question for the physician to answer. A compliant query asks the physician to clarify existing documentation/facts present in the record.

A compliant query should not and must not be “leading” in nature.
What do we mean when we talk about avoiding “leading queries?”

Per AHIMA:
“A query is never intended to lead the provider to one desired outcome. The query must provide reasonable, clinically supported options, include clinical indicators, and must not result in a yes/no*. They must include the option that no additional documentation or clarification can be provided.”

*There are a couple exceptions (as always) to the yes/no rule, discussed later in part 3
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Example of a Leading Query

Dear Dr. Jones,
Based on your documentation, this patient has anemia and was transfused 2 units of blood. Also, there was a 10 point drop in hematocrit following surgery.  Please document “acute blood loss anemia,” as this patient clearly meets the clinical criteria for this diagnosis.

This is non compliant and will lead to trouble. The query intent is NEVER to tell the physician to document something.


For more information contact:
Christopher G. Richards, RHIA, CCS
Senior Associate, Barry Libman, Inc.
crichards@barrylibmaninc.com
www.barrylibmaninc.com
- See more at: http://www.libmaneducation.com/physician-query-process-part-2-describe-general-aspects-of-a-compliant-physician-query/#sthash.BuUKEJoc.dpuf