How to Query Providers to Achieve Complete Documentation

Coding professionals face increasing challenges to code claims accurately. Facilities can help ensure documentation integrity and coding accuracy by establishing and managing an effective query process. The importance of complete documentation in the patient’s health record cannot be overstated; without such documentation accurate coding cannot be assigned.

Coders should query the provider for clarification and additional documentation when there is conflicting, incomplete, or ambiguous information in the patient’s health record regarding a significant reportable condition or procedure or other reportable information (e.g., present on admission indicator). The query process should ensure that the physician documents the requested clarification or additional information in the patient’s health record. Physician query forms, attestation forms or coding summary sheets are not necessarily sufficient – the physician should document the information in the medical record. A provider’s response to a query can be documented in the progress note, discharge summary, or on the query form as a part of the formal health record. Addendums to a discharge summary or progress note should include appropriate date and provider signature.

Querying can also be used as an educational method to foster documentation improvement practices. Examples of query situations include:

• Clinical indicators of a possible diagnosis without documentation of the condition
• Clinical evidence suggests a higher degree of specificity or severity
• A cause-and-effect relationship between two conditions or organism
• An underlying cause when admitted with symptoms
• Treatment is documented without a documented diagnosis
• Present on admission (POA) indicator status

Only diagnosis codes that are clearly supported by provider documentation should be assigned. Lack of accurate and complete documentation results in the use of nonspecific or general codes, which can impact data quality, potentially lower reimbursement and may create potential compliance risks.

Queries should not be used to question clinical judgment. Use queries to clarify documentation when it fails to meet any of the five criteria of legibility, completeness, clarity, consistency, or precision. A query should include the following:

• Patient name
• Admission date and/or date of service
• MRN
• Account number
• Date query initiated
• Name and contact information of the person initiating the query
• Statement of the issue in the form of a question along with clinical indicators specified from the chart (e.g., H&P reflects urosepsis, labs WBC of 14,400. ED report fever 102F)

Written By Sandra Inocencio, RN, CPC, CCP