ED Coding and Reimbursement Alert

Keep provider interactions as simple as possible.

If you require additional information from a provider but are too intimidated to ask — or you don’t get answers you need — it can have a negative effect on your coding. If you discover what you can do to navigate querying a provider with confident, concise communication, you’ll reap the benefits of cleaner claims.

“If you can establish a relationship with your provider, you’ve done 75 percent of the work in coding and querying,” Emily Schmidt Barnette, CPC, CPC-P, CDEO, CPB, CPMA, CRC, CPC-I, said during the 2023 HEALTHCON presentation, “Communicating with Providers.”

Check out this advice on keeping the communication channels open with providers in case you do need to query them.

Know the Common Reasons to Query

You may need to query your provider for any of the reasons below:

• Legibility: If you as the coder cannot read and input the information, you will need to query.
• Completeness: At times, there may be clinical indicators such as diagnostic labs, imaging, pathology, or prescribed medications found within the patient’s medical record. If they, or other elements of medical care are not documented by the provider, you should query.
• Clarity: Oftentimes, signs and symptoms may be reported or present in the medical record, but your provider hasn’t established a definitive condition, which could be a reason to query.
• Consistency: Consistency involves variances within the medical record. If there are any inconsistencies in the notes from the beginning to the end of the encounter, you need to query.
• Precision: Although ICD-10 gave us an opportunity for increased specificity in code assignment, to assign codes to the highest level of specificity, we must have matching and supporting documentation.

Know How to Present a Query

Queries may be written or verbal and generated in one or more of the following ways:

• Concurrent (while the patient is still under treatment)
• Retrospective (post encounter)

“The technique of writing a query is critical in ensuring clear and precise communication to a provider. Make sure that the question you are asking makes sense with the information you are providing as support. I like to use ‘specify and clarify’ in my queries, but any language will work provided the doctor understands the query,” says Vida Rothstein, RHIT, CCS, AAPC inpatient auditor for Audit Service Group in South Bend, Indiana.

All queries should then follow the same format whether they are written, emailed, or delivered over the phone, stressed Schmidt Barnette. They should:

• Be clear, concise, and non-leading;
• Contain simple and direct language;
• Itemize the clinical indicators or clues from the health record, and
• Contain all the patient’s identifying information such as name and date of service, as well as clinical findings with supporting documentation that results in a specific question for the provider.

“It’s important to avoid leading the provider with your language. “You want to avoid saying things like, ‘Please document if you agree that the patient has _________,’ and instead ask questions that will help you narrow down the correct coding,” Schmidt Barnette suggested. You should ask more specific questions like, “Based on your clinical judgment, can you provide a diagnosis that represents the below listed indicators?” to get to the correct diagnosis.

It’s essential to use compliant query templates for written and emailed queries, as Schmidt Barnette emphasized during the presentation. This ensures consistency and accuracy in documentation across the entire office.