Continuity of patient care depends on communication among healthcare providers. It is not feasible for providers to always talk face to face about a patient. So, complete and accurate written communication is vital. Queries are an important tool used to achieve this.
When the documentation is lacking, the resultant coded data may be inaccurate. So, why would that matter? Most queries are written to clarify documentation as it relates to reimbursement. However, code assignment not only impacts reimbursement, but also other significant uses of coded data. Ideally, queries would be written as necessary to ensure data integrity, as well as accurate documentation. However, facility policy may limit the instances when a coder is permitted to query.
According to an AHIMA position statement, coded data from a patient’s health record may be used to:
- Assist with clinical performance improvement
- Measure the quality, safety, severity of illness, and efficacy of care
- Manage care and disease processes
- Track public health and risks
- Provide data to consumers regarding costs, quality, and treatment option outcomes
- Design payment systems and process claims for reimbursement, including pay-for-performance measures
- Perform research, epidemiological studies, and clinical trials
- Serve as “clinical” data set for some personal health records
- Design healthcare delivery systems and monitor resource utilization
- Identify fraudulent practices
- Set health policy
If the coded data is based on incomplete and inaccurate documentation, decisions may be made with unintended adverse consequences. It is the job of the coder to know when to query and what to query so that the end users can make the best decisions.
The bottom line is that the impact of querying is more important than health care professionals probably realize!
The information contained in this query advice is valid at the time of posting. Readers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.