After a patient is discharged, coders often desire additional clarification or information from the attending physician before they feel they can code from the medical record. A common method for coders to obtain additional information is to submit a "query form" to the attending physician. The query form provides an opportunity for the physician to state more clearly or confirm the diagnosis of a patient as reflected in the medical record. Often these forms are used when other pieces of documentation, such as a discharge summary, are not yet available to the coder.
Physician queries have also been used to confirm certain diagnosis codes that have been scrutinized by the government. For example, in some situations a coder might query a physician to determine whether a patient should be diagnosed with the higher-paying gram negative pneumonia (instead of the lower-paying unspecified bacterial pneumonia) or to determine whether the physician’s usage of the vague term "sepsis" should be understood to refer to (higher-paying) septicemia or (lower-paying) urinary tract infection.
1. Example Open-Ended Query
2.Example Multiple Choice Query
3.Example Yes/No QueriesCompliant Example 1
Compliant Example 2
Compliant Example 3
Non-Compliant Example 1
Non-Compliant Example 2
Non-Compliant Example 3