Otolaryngology Coding Alert

Answer: There are generally three types of queries coders can use, depending on the situation:

1. The Y/N option: The question is written so that it can only be answered with a “yes” or “no,” and does not lead to another question. Often used to identify cause-and-effect relationships, identify manifestation and cause, clarify conditions and diagnostic findings, or investigate conflicting documentation between providers.

Example: The patient had an excisional biopsy of a suspicious lesion, and the pathology report notes squamous cell carcinoma. Do you agree with the pathologic findings?

• Yes – agree with pathologic findings
• No – do not agree with pathologic findings

2. Multiple-choice option: Useful when faced with several diagnoses that are supported by the medical record. For this type of question, include clinically significant and reasonable options as supported by clinical indicators in the health record — recognizing that, occasionally, there may be only one reasonable option.

Example: The patient presented with redness and swelling of the ear and EAC. The documentation states bilateral acute noninfective otitis externa. Please clarify if the patient’s external ear inflammation is:

• Acute actinic otitis externa
• Acute chemical otitis externa
• Acute contact otitis externa
• Acute eczematoid otitis externa
• Acute reactive otitis externa

Other noninfective acute otitis externa

3. The open-ended option: Useful when there is not enough information to create a multiple-choice or a yes/no query. For example, when there are clinical indicators in the note for a diagnosis but there is no diagnosis noted. This type of question allows the provider to write their own text as a response.

Example: Patient presents with ear pain. History and exam reveal chronic otitis media (OM) over the past six months, with multiple antibiotics prescribed, and continued redness and inflammation of the external ear. However, the assessment and plan (A/P) does not include a diagnosis of OM, nor is there an indication of an antibiotic prescribed, but the patient.is to return in two weeks. Based on your clinical judgment, can you provide a diagnosis that represents the clinical indicators documented above and reconcile any documentation discrepancies?

Tips: Always use a consistent, compliant format. Make sure to state the facts simply and refrain from making questions overly wordy. Most importantly, remember that queries should never include the impact on revenue or lead the provider to answer a certain way.