Query Question is Key

The best way to get a physician to answer a query is with a question that makes sense and eliminates guessing as to what is being asked.

Some helpful hints:

Ask the question “What do I need to know?” and write down the response.  Usually this will need very little editing in order to be used as the query question.

• Discharge summary states that the patient was treated for cystitis.  The patient is a nursing home patient with a long term Foley catheter.  What does the coder need to know?? – was the cystitis due to the Foley?  With just a little editing, the coder could ask:  “Can you clarify if the cystitis is related to the presence of the catheter?” 

Write the question in the form of a question, not a statement.

• “Please specify if the cystitis is related to the presence of the catheter,” is considered directive and leading, plus it is not a question.

Be as clear, concise, and simple as possible.

• “Can you clarify if the E. coli sepsis found on this admission was in any way related to the pedicle screws placed during the L3-S1 spinal fusion performed on the posterior column six months ago?”  This question will probably cause the physician’s eyes to “glaze over.”  A simpler and more concise question would be “Can you confirm any relationship between the sepsis and hardware from previous spinal fusion?”

Do not introduce a new diagnosis in the question.

• Patient is admitted with several clinical indicators of sepsis, but the diagnosis is never given in the record documentation.  Final diagnosis on the discharge summary is bacteremia.  What does the coder need to know?? – is this sepsis?  Since sepsis was never documented in the record, the question cannot be “Did the patient have sepsis?” because that would be leading.  A better choice might be:  “Can the bacteremia be further clarified?”  Sepsis could then be listed as an option for response.  

Do not include the options for response in the question.

• A question such as “Can you confirm if TIA was ruled in, ruled out, or unable to determine?” may seem confusing to the physician.  It is simpler and more concise written as:  “Can you confirm the diagnosis of TIA?”  The options for response would then be listed separately.