General Surgery Coding Alert

Look to CMS for guidance.

When you need to clarify an op report with your surgeon, you should know how to complete your query in a productive way.

Remember: A productive query not only clarifies the single claim you’re working on, it also shows providers where they can improve their documentation – which helps you code more accurately in the end.

Bolster your skills with advice that Leonta Williams, RHIT, CPCO, CPC, CEMC, CHONC, CCD, CCDS, offered during a presentation at this year’s virtual HEALTHCON conference.

What Exactly is a Query?

You write a query when something about the physician’s documentation is confusing, conflicting, or lacking in detail.

First step: Before you submit a query, brush up enough on your clinical skills to understand what you’re reading, Williams stresses. If you submit a query about clinical information you should know, “that lessens your credibility” in your practice, she said.

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.

Follow CMS Query Guidelines

Williams says your query forms should:

• 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.

Rumors abound that some physicians are asking coders to mention reimbursement dollar amounts in their queries. Make sure you steer away from that practice and follow CMS guidelines to remain compliant. Never mention dollar amounts in your queries, Williams stresses.

Include These Elements – in Writing

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 “don’t box the provider in,” Williams said. Steer clear of “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?” according to Williams. Instead ask, “Why was the patient given IV fluids?” Pay close attention to the headings you use for written queries, Williams cautioned, because sometimes headings can also be leading.

Tip: You might ask for an addendum or provide multiple-choice options that include an “other” option to help the provider articulate their thinking in the medical note.

Final tip: “Avoid the words ‘you’ and ‘but’ in your queries,” Williams advised. 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.”