Oncology & Hematology Coding Alert

Master writing techniques that transform a leading query into a non-leading query.

'Leading' queries hamper your clinical documentation improvement efforts (CDI) and can cause all sorts of compliance headaches, warned Leonta Williams, RHIT, CPCO, CPC, CEMC, CHONC, CCS, CCDS in a class she taught at the American Academy of Professional Coders Regional Conference in Salt Lake City. Williams, director of Medical Coding at Georgia Cancer Specialists, challenged AAPC attendees to identify which of the two queries below are leading:

1. Dear Dr. X: The documentation indicates only lung cancer (unspecified); however, a diagnosis code of head and neck cancer was assigned to the chemo order. Please also add the head and neck cancer to the assessment in your progress note.

2. Dear Dr. Y: The pt's weight is 385 lbs and has a BMI over 50%. Overweight is documented in the HPI and the assessment states obesity. Due to the recorded weight and BMI would you agree the patient is morbidly obese?

Question: Which of the above queries are leading?

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Answer: Both of them, said Williams. "The query to Dr. X is so leading it isn't even a query; it's an order," quipped one conference attendee. "The query is basically telling the provider what to do."

Coders read so many notes that we sometimes think we know what the physician meant to say. "Always leave your query open-ended, even if you think you know the answer," Williams told the class.

The query to Dr. Y is attempting to resolve what appears to be conflicting information in the note, but it is leading because it asks for one diagnosis only and doesn't leave the question open-ended enough for the provider to consider more than one diagnosis, Williams said.

Phrasing the query as a yes or no question and also including options for the physician to document "undetermined" or elaborate on the yes or no question can help you revise a leading query, Williams told AAPC conference attendees.

Study This Example To Learn How To Revise Leading Queries

Leading Query: Dear Dr. Z: The pathology report lists kidney cancer; however, kidney mass in documented in you're A/P. Please sign the below stating agreeance with kidney cancer.

X__________________________

The Fix: A useful revision strategy is the multiple-choice format, Williams said. Just make sure you include "other" among the choices so that the physician may document something other than what you suggested. You might also include "undetermined" among the choices if you think the physician could be waiting on the results of diagnostic tests.

The Revision: Dear Dr. Z: The pathology report lists kidney cancer; however, kidney mass in documented in you're A/P. Do you agree with the pathology statement specifying kidney mass as cancer?

______________Yes

______________No

______________Clinically Undetermined

______________Other

Resources:

To learn more about physician queries, see the article on p. 93.

To read the AHIMA article "Writing Effective Physician Queries," go to: http://www.fortherecordmag.com/archives/110711p14.shtml.

To see query examples from experts, go to this Journal of AHIMA article: http://journal.ahima.org/2013/02/01/physician-query-examples/.