Gastroenterology Coding Alert

Question: Thank you for your article last month on documentation tips. We read it and have a follow-up question. One of our newer GI physicians often creates documentation that’s missing the details we need to select the right code. We sometimes have to ask him for more details. One of the other physicians said that to make it easier, we should show the new doctor the dollar amounts of the different codes when we send him a query for more information. What’s the right way to go about this?

Florida Subscriber

Answer: You can definitely send a query when the documentation seems to be missing a key fact. For example, the note may contain signs and symptoms, but not a documented condition, and you’re fairly sure the provider isn’t waiting on lab or biopsy results. Or the note might contain what appears to be conflicting information. Or perhaps you need additional information in order to assign the correct ICD-10-CM code. You might even be dealing with a paper record that contains illegible handwriting.

When you query the doctor for more information, consider including the following:

• Be clearly and concisely written
• Present the facts and identify why the clarification is needed
• Present the scenario.

Query forms should not:

• Be designed so that the only thing needed is a physician’s signature
• Indicate any financial impact.

Although the physician asked you to mention reimbursement dollar amounts in your queries, that’s not a recommended practice. Make sure you steer away from that request, and avoid discussing money in your requests.

Here’s how you can mention money: One way you can tell your doctors about money they’re leaving on the table is to create an adjustment code for bad documentation (i.e., BD), and you’ll use that to denote services that weren’t billable due to problematic documentation. At the end of three to six months, show the doctor how much they have lost due to the “BD” adjustment code.

Written queries are best, but they can be verbal as long as you document the verbal exchange. Queries can even be conducted over email — provided your practice’s email system is secure and HIPAA-compliant.

The written form or verbal documentation should list the following:

• Patient’s name
• Date of service
• Medical record number
• Provider’s name
• Name and contact of the individual sending the query
• Date of query
• Statement of the issue (in the form of a question or request for additional information).

Don’t lead: Word your query carefully so that you avoid creating leading queries that give providers only one way to answer the question, even if you think you know what the provider meant to document.

For example, don’t ask, “Was the patient given IV fluids because she was dehydrated?” Instead ask, “Why was the patient given IV fluids?”

Final tip: “Avoid the words “you” and “but” in your queries. Such language can sometimes provoke a defensive reaction. Instead, consider: “Please provide the patient’s condition necessitating the infusion of the 1000 ml of normal saline administered.”