Optum360 coding books logo
    Contact Us   (7 a.m.–7 p.m. CST)
  Home > Coding Central Articles > Coding Central Articles  
Coding Central
Coding Central Home
Inside Track to ICD-10
Coding Central Articles
Code This!
Case Studies
Chargemaster Corner

Articles for:
February 14, 2018

Select States and Territories to Be First to Receive New Medicare Cards

The Centers for Medicare and Medicaid Services announced its mailing strategy over the course ... Learn More

New Payment Model Qualifies as APM

The Centers for Medicare and Medicaid Services (CMS) is rolling out a new payment model to begin ... Learn More

MAO Provider Directories Frustrate Would-Be Patients, CMS Finds

In a review completed in August 2017, the Centers for Medicare and Medicaid Services (CMS) dis... Learn More

View Article Archive

To subscribe, paste this link into your preferred feedreader, or click on one of the buttons below:

Medical Coding News Archives

Steering Away from Leading Physician Queries

March 15, 2017:

One of the greatest challenges of formulating physician queries is avoiding asking leading questions. Assuming too much or guiding the physician toward an answer is considered noncompliant with best practices and can lead to problems if records are audited.

With the implementation of the very specific ICD-10 codes this past fall, coders may find themselves having to query physicians more often. Figures from a 2013 survey by the Association of Clinical Documentation Improvement Specialists (ACDIS) revealed that a substantial percentage of records prompted queries—most clinical documentation improvement (CDI) professionals reported querying between 10 percent and 40 percent of the records they reviewed. This percentage may very well rise in response to the extra detail required to code accurately under ICD-10.

The American Health Information Management Association (AHIMA) defines a leading query as a query not supported by clinical information in the medical record or one that directs a provider to a diagnosis or procedure. For instance, “Is the patient’s diagnosis CHF?” would be considered a leading query because it suggests an answer to the physician. The better query involves the open-ended question, “Based on the following clinical indicators in the medical record, can you identify a diagnosis?”

Queries can also be phrased as multiple choice or yes/no questions. Again, they cannot be leading. For instance, if the physician mentioned congestive heart failure in the documentation and systolic dysfunction is noted in an echocardiogram but the physician did not specify the condition as systolic CHF, including “systolic CHF” in all the multiple choice options is considered leading and therefore noncompliant. However, introducing a new diagnosis as just one of the options in a multiple choice query is not considered leading. It is also important to include an option such as “clinically undetermined” or “other” so that the provider can add information by hand.

In the CHF case above, the coder could use a yes/no question such as, “Given the clinical indications in the medical record, echocardiogram results, and using your clinical judgment, could the CHF be further specified as systolic CHF?” As with the multiple choice query, the yes/no query should include an area where the provider can add free text by offering “other” or “not clinically significant and integral to” as boxes they can check, along with blank lines for writing.

According to AHIMA, when the medical documentation contains only clinical indicators and no diagnosis, there is no way to form a yes/no question that is not leading. Presenting the clinical indicators with an open-ended query would be appropriate in this situation.

Verbal queries should follow these same rules to avoid being considered leading. All verbal queries should also be documented in the record, along with the clinical indicators that prompted the queries.

The Journal of AHIMA offers examples of compliant and noncompliant physician queries at the following site: http://journal.ahima.org/2013/02/01/physician-query-examples/


Sign in to
Your Account
Forgot your username?
Forgot your password?
Don't have an account?
It's easy to create one.
Promo code

Have a promotional source code? Enter it here:

What is this?
Shop our catalog
Request or check out the electronic version of our latest catalog.

Medical Coding Books Winter 2018 Catalog