What should be included in a physician query?

AHIMA guidelines state that a query should be considered when health record documentation includes the following:

  • Conflicting, imprecise, incomplete, ambiguous, or inconsistent documentation.
  • Associated clinical indicators related to a specific condition.
  • A diagnosis without an underlying clinical validation.

What is the process when you query a physician?

“A physician query is defined as a written question to a physician to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record.”

What is a query diagnosis?

Query diagnostics provides two views: summarized and detailed. The summarized view “collapses” multiple related operations into a single operation. In this process, details collected by each operation are combined, and the exclusive durations are summed. No information is lost as part of this process.

What is a leading physician query?

A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format.

What type of information should a query contain?

The query should include the documentation in question with relevant clinical indicators and be constructed so that it can be answered with a “yes” or “no” response.

Which of the following requires a query to the physician regarding clinical documentation?

A process to facilitate the accurate representation of a patient’s clinical status in the patient’s health record. Which of the following requires a query to the physician regarding clinical documentation? Documentation is conflicting, incomplete, illegible, ambiguous, or inconsistent.

What is a clinical documentation query?

Documentation queries are sent by the Clinical Documentation Improvement team and Health Information Management in an effort to develop a medical record that accurately reflects the patient’s Severity of Illness (SOI), Risk of Mortality (ROM), and the care being provided.

What is an example of leading query?

What’s an example of a leading query? In a 2008 practice brief, AHIMA gave this example. An obtunded patient with a three-day history of nausea and vomiting was admitted. A chest X-ray revealed right lower lobe pneumonia, and the patient received clindamycin.

What is a clinical validation query?

What is Clinical Validation? ▶ The process of clinical review of a claim to see whether or not the. patient really has the conditions that were documented. ▶ Performed by a clinician, retrospectively after claims submission.

What is the purpose of the physician query process quizlet?

A proper query process ensures that appropriate documentation appears in the health record. Personnel performing the query function should focus on a compliant query process and content reflective of appropriate clinical indicators to support the query.

Which of the circumstances below would justify a query to the physician regarding clinical documentation?

Is a query part of the medical record?

Query retention policy It is recommended that the policy specify the completed query be a permanent part of the health record and the location. If it is not considered a permanent part of the health record, it should be considered as part of the business record and retained for auditing, monitoring, and compliance.

What is the most important part of the physician query equation?

Follow Up, Repetition, and Persistence – This may be the most important part of the equation. For now, let’s focus on the physician query piece of the equation. For convenience, I will use the term “addendum” in place of all terms modifying the record after the fact, whether that be a “late entry,” “amendment,” or “correction.”

What is a a query?

A query can be a powerful communication tool used to clarify documentation in the health record and achieve accurate code assignments. This Practice Brief In Addition provides examples of the different forms of queries available to HIM professionals.

What is an example of a physician trying to avoid queries?

For example, if a physician suddenly starts documenting that every patient with pneumonia has bacterial pneumonia, he or she may be doing so to avoid a query. That doesn’t benefit anyone because it introduces incorrect information into the medical record.

Can a new diagnosis be derived from a “yes/no” query?

A new diagnosis may not be derived from a “yes/no” query. As an example, for Medicare Advantage and the Marketplace, I query only for Hierarchical Condition Categories (HCC) clarification, not for RxHCC.