Now that severity of illness has been examined, the Hospital executives would like to look at the impact of the record completion and physician query process, as it relates to reimbursement.

Now that severity of illness has been examined, the Hospital executives would like to look at the impact of the record completion and physician query process, as it relates to reimbursement. The coders at Independence Hospital are asked to follow up on physician queries as part of the record completion process. The coders should query the physician when documentation in the patient’s record is not sufficient to support the diagnosis in the medical record.  A physician query form is used as a  method of communication between the coder and the physician to address documentation that is not sufficient to support the diagnosis.

Case Scenario

Patient: Sally James

DOB: 10-14-1960

MR#123-34-78 

Admitted: 01-13-2018

Physician: Ervin Mass

The impression on the pathology report, ovarian cancer is documented; however, only ovarian mass is documented in the final discharge statement by the provider.

Develop a physician query form that addresses incomplete or insufficient documentation in the case scenario listed above.

The query form must include the following:

1. Patient Identification Information

2. Date of Service

3. Coders Name & Contact Information

4. Query Date

5. Name of Physician 

6. Statement of the issue (as it relates to incomplete, vague or insufficient documentation)

According to AHIMA, queries should be written with precise language, identifying clinical indications from the health record and asking the provider to make a clinical interpretation of these facts based on his or her professional judgment of the case. 

Develops a physician query form.

Physician query form addresses incomplete or   insufficient documentation.

Physician query form is written with precise language,   identifying clinical indications from the health record

Physician query is asking the provider to make a   clinical interpretation.