Implement a compliance process in your practice for querying providers for outpatient services.
Querying providers about their documentation may seem inappropriate, but it is an important part of the medical coding process. A physician query allows a medical coder to formally ask a healthcare provider a question about something they wrote (or didn’t write) in a patient’s medical record. As a director or manager within your organization, it’s your responsibility to implement workflows and policies for physician queries; and as a medical coder, it’s your responsibility to query providers when necessary to ensure their documentation leads to correct code assignment, proper payment, and quality care.
In this article, we’ll answer your questions about when and how to query a provider in the outpatient setting.
When to Query the Provider
The outpatient record of service should tell the story as to why the patient was seen that day (chief complaint), what information was collected that day (history of present illness, review of systems, and past, family, and social history), which body areas or organ systems were examined (exam), whether a final diagnosis was made, and how the provider will manage the patient’s diagnosis through their assessment and plan (A/P).
Coders should query any time there is missing information, conflicting documentation (including that between providers), statements without clear support, or illegible documentation.
Queries should be sent at the time an issue is encountered; waiting to query will compound the problem.
AAPC Services recommends coders query when documentation is insufficient and does not:
- Clarify the reason/intent of the visit.
- The Centers for Medicare & Medicaid Services states that any visit without a chief complaint does not support medical necessity for said service.
- Clarify the reason/intent for tests and/or procedures.
- Verify the status of established complaints.
- Is the condition active or resolved? If active, is the condition stable, worsening, or not at goal? The answer to this query could affect the overall assigned level of service based on the 2021 evaluation and management guidelines for patient complexity.
- Establish the acuity of a diagnosis.
- What are the medical needs to support? Is the condition acute, sub-acute, or chronic?
Another consideration is whether the patient is at a greater risk of complications due to a condition that may be noted but is not connected as a complication in the A/P. The ICD-10-CM Official Guidelines for Coding and Reporting states, “An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.”
How to Query
Coders can query any provider they are coding for, whether it is a physician or other qualified healthcare provider. As a manager, teaching your coders the proper way to write queries is an important step in implementing a physician query process.
There are generally three types of queries coders can use, depending on the situation:
1. The Y/N option: The question is written so that it can only be answered with a “yes” or “no,” and does not lead to another question.
Example: The patient had an excisional biopsy of a suspicious lesion. The pathology report notes that the patient has squamous cell carcinoma. Do you agree with the pathologic findings?
Yes – agree with pathologic findings
No – do not agree with pathologic findings
2. The multiple-choice option: For this type of question, include clinically significant and reasonable options as supported by clinical indicators in the health record — recognizing that, occasionally, there may be only one reasonable option.
Example: The patient has a history of mild asthma and presented for this visit with a complaint of shortness of breath when playing at recess and occasionally when walking up stairs. Please clarify if the patient’s asthma is:
- Mild intermittent without complication
- Mild intermittent with acute exacerbation
- Mild persistent without complications
- Mild persistent with acute exacerbation
3. The open-ended option: This type of question allows the provider to write their own text as a response. Use when there are clinical indicators in the note for a diagnosis but there is no diagnosis noted.
Example: History and exam revealed elevated blood pressures over a specified timeframe, however, A/P does not contain any diagnosis of such (hypertension (HTN) or elevated BP without diagnosis of HTN). Based on your clinical judgment, can you provide a diagnosis that represents the clinical indicators documented above?
Always use a consistent, compliant format, no matter which option you use. Additionally, state the facts simply and refrain from making questions overly wordy. The most important thing to remember is that queries should never include the impact on revenue or lead the provider to answer a certain way.
Put Queries in Their Place
Queries should be documented within the patient’s health record, either as part of the office visit note, an addendum, or saved in another area that is linked to the date of service in question. Having the provider’s response documented in the health record is the only way the query can be used for coding purposes.
Due to the ongoing demand for queries, a lot of electronic medical records (EMRs) already have query templates built in, but they may not be activated. Reach out to the vendor to find out if your EMR has a built-in query feature; otherwise, you can create a standard text document to use and store physician queries.
Queries Are a Team Effort
The medical record of service is a legal document and should contain a description — or itemization, if you will — of what medically necessary services were provided and what diagnoses warranted those services relating to that day’s encounter. Clear, concise documentation impacts more than just code selection and proper payment. Medical record documentation impacts areas such as case management, quality management, infection control, and more.
Knowing when and how to write a physician query can be challenging for even the most seasoned coder. A formal process and training should exist in every practice. Accurate documentation is a team effort, and we all play an important part on the team.
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