One of The Best Strategies for Risk Adjustment Medical Coders: Query the Physician or Other Healthcare Provider

Medical records report the care a patient received in a chronological order and are used to record pertinent findings and observations about the patient's health history. Medical record documentation assists physicians and other healthcare professionals in evaluating and planning the patient's immediate treatment and monitoring the patient's healthcare over time. Therefore, the medical documentation is essential and must be clear and concise.

Apart from the possibility, according to ICD-10-CM Guideline I.A.15, to link certain diagnoses themselves, the medical coders do not have any power of diagnosis coding decision. They must apply a strict literal interpretation to the healthcare provider's medical record documentation. They are not allowed to make assumptions or presume to know the healthcare provider's intent. They cannot apply a clinical interpretation to information within the record. Accurate diagnosis code assignment is dependent on the healthcare provider clearly describing each medical diagnosis to the higher level of specificity. 

The only way the coders can influence the medical documentation is through Physician Query, which is a method of communication used by coders to request clarification from the physician about patients' diagnoses or procedures. The desired outcome from a query is an update of a health record to better reflect a physician's intent and clinical thought process documented in a manner that supports accurate code assignment. 

The generation of a query should be considered when the medical record documentation:

Query can be worded differently but should never be interpreted as leading the physician. Query should never be initiated without a basis of the patient's symptoms or treatment that clinically indicates a specific condition. These symptoms and treatments are referred to as clinical indicators that are represented as well by lab results, radiology reports, and conflicting or unclear documentation. Having a basic understanding of clinical indicators allows medical coders to verify if patients present with a possible diagnosis or if there are inconsistencies in the documentation. Therefore, knowing clinical indicators is knowing when it is appropriate to query a physician.

A query can be constructed in different manners, including the following:
a) Open-Ended Query
It allows the physician to clarify the documentation.

Example of open-ended query
A 70-year-old man with pancreatic cancer showed up at the office yesterday for a post-hospitalization visit. The progress note describes the patient as underweight, unintentional weight loss over past 2 months. Nutritional consult notes BMI is 18.6 with muscle wasting. Recommendations include nutritional supplements and vitamins.

Based on your clinical judgment, can you provide a diagnosis that represents the below-listed clinical indicators?

b) Multiple-Choice Query
It is used to establish greater specificity to a diagnosis and should include options supported by the clinical indicators in the patient's chart. It should include choices such as:

It is appropriate to also include new diagnosis as an option when supported by clinical indicators.

Example of multiple-choice query
It is noted in the assessment of the progress note that the patient has Chronic Heart Failure and recent echocardiogram noted under the cardiac review of systems reveals an EF of 25%. Can you further clarify your diagnosis of Chronic Heart Failure?  

c) Yes/No Query
It can be used to:

This type of query should never be used to verify or document a condition that is not already established in the patient's medical record. But besides Yes and No, it should include other options such as Other _______, Undetermined, and/or Not clinically relevant.

Example for Yes/No query
A 64-year-old man is presented at the office for a follow-up of hyperlipidemia that has been diagnosed for 4 years. The patient's home medications include Lipitor, Zetia, and omega-3 fatty acid supplements. Today, he complains of tingling feet and fingers. In the assessment, the following diagnoses are documented: Peripheral neuropathy, Hyperlipidemia.

Is the Peripheral Neuropathy due to Hyperlipidemia? Please document your response below.

The documentation in the medical record is essential for coding and reimbursement. This is also critical for caring for the patient. Healthcare providers often get focused on the treatment and give less time for the documentation.  Going to the providers to obtain more information is an important link. Medical coders can help providers realize things in the documentation that they need to include—which helps with reimbursement, as well as helps in patients' treatment.

With each provider, medical coders can find a way to approach them and be the key to complete these gaps as to provide accurate records and documentation of the care that is given. The information obtained from the queries will assist to clarify discrepancies and make it possible to accurately report services performed and ensure fair compensation.
Query serves as an educational tool to improve physician documentation and the medical coders' understanding of clinical scenarios.

Yves-Edouard Baron, CPC, CPMA, CRC, CDEO, ACDIS CDI-a, is the CEO of La Ste-Famille MRA Auditing, LLC., offering services for private physician offices with MRA chart reviews, clinical documentation education, and MRA training for new MRA coders.