Writing a Query Question – Simple and Concise is the Key

The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking. That way the response will be as specific as possible and eliminate the need for an additional query. The trick to writing an effective query question is to just ask oneself “What do I want to know?” The reply to that in most cases will be the basis of the query question. For example, if the coder wants to know what caused the patient’s chest pain, the final query question could be “Can you specify the cause of the patient’s chest pain?” There does not need to be any further verbiage to confuse the issue. It is as simple as that!

Below are examples of typical query questions:

LINKING ORGANISM TO INFECTION:
“Can you identify the specific organism responsible for patient’s pneumonia?”

CLINICAL FINDINGS WITHOUT DIAGNOSIS:
“Can you provide the condition described by the clinical indicators listed above?”

TYPE AND ACUITY:
“Can you further clarify the type (and/or) acuity of patient’s CHF?”

PATHOLOGY RESULT:
“Can you confirm any clinically significant diagnoses represented by the pathology finding(s) outlined above?"

CAUSE OF SYMPTOM:
“Can you specify the cause of patient’s chest pain?”

DIAGNOSIS OCCASIONING THE ADMISSION:
“Can you clarify the condition(s) that occasioned admission to the hospital?”

POA:
“Can you determine if the patient’s sepsis was present on admission?” 

Be sure that relevant clinical indicators are also included in the query. Reasonable and clinically supported options for response can be listed, if desired.

For more than 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

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.