A query question that is directive in nature, indicating what the provider should document, rather than asking for his/her professional determination of clinical facts, constitutes a leading query. The provider should not be made to feel obligated to document anything. One way to avoid being directive is to phrase the query question as an actual question.
Many coders in trying to be polite and respectful end up writing a directive query. “Please document…” is frequently used by coders to begin their query. This would be considered a directive statement rather than a question. Coders can restate the statement as “Can you clarify…” Terms such as confirm, specify, or indicate may also be used, depending on the purpose of the query.
Other directive statements seen in queries include “Coding guidelines require…” or “The DRG may be impacted…” Many providers are not concerned with coding guidelines, payment implications to the hospital, or other nonclinical issues. A query should only be used for documentation clarification. Statements regarding coding guidelines, Coding Clinic advice, or DRG impact have no place in a provider query since that information is only relevant to the coder.
Examples of Directive Query Questions
Please document the cause of patient’s altered mental status.
Coding guidelines state that symptoms should not be coded if the underlying cause is known. Document the cause of the patient’s confusion in the discharge summary.
If the patient’s CHF is exacerbated, the DRG will be affected. Please indicate the CHF acuity during this admission.
Examples of Nonleading Query Questions
Can you clarify the cause of patient’s altered mental status?
Can you confirm the cause of patient’s confusion?
Can you specify the acuity of patient’s CHF during this admission?
The information contained in this query advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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