The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query. However, if the physician fails to clarify the issue being questioned, the coder faces the need to come up with the clinical indicators to complete the query. If no notes are made along the way, the coder is left struggling to identify supporting documentation and its location in the record. If the coder has a long stay record, that task can be very daunting and time-consuming.
It is imperative that coders not only identify a potential query as soon as possible in the coding process, but to make key notations along the way to support it. This may seem like a lot of work for nothing if at the end a query is not needed. But, conversely, it could save a tremendous amount of time if a query is deemed necessary.
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.