Outpatient Facility Coding Alert

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

"Leading" queries hamper your clinical documentation improvement (CDI) efforts 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 three 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?

3. Dear. Dr. Z: It is noted in the A/P that the patient has chronic congestive heart failure. The most recent echocardiogram revealed an EF of 25%. Can the CHF be further specified as:

• Systolic CHF
• Diastolic CHF
• Systolic and Diastolic CHF.

Question: Which of the above queries are leading?

Answer: All three of them, Williams said. "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."

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, Williamssaid.

The query to Dr. Z is leading because it gives the provider only a limited set of choices, and it doesn't leave room for the provider to consider their own choice. It also fails to mention "acute" and "chronic" options, Williams pointed out. Even though your query must never mention financial impact, specifying whether the CHF is acute or chronic is simply good coding and can make a big reimbursement difference.

Study These Examples To Learn How To Revise Leading Queries

Leading query #1: Dear Dr. X: The pt has a documented diagnosis of PNA that is being treated with Vancomycin IV. Since Vancomycin is used for gram-negative organisms, please document that the pt has gram-negative PNA in your progress note.

The fix: Coders read so many notes that we sometimes think we know what the physician meant to say. The query above is leading the physician to describe the PNA as gram-negative. "Always leave your query open-ended, even if you think you know the answer," Williams told the class.

The revision: Dear Dr. X: The patient has a documented diagnosis of PNA that is being treated with Vancomycin IV. Please clarify and document in the progress note the type of PNA being treated.

Leading query #2: Dear Dr. Y: Pt discharged from St. Mary's hospital 3 days ago with a GI bleed. Today seen in GI clinic with HGB of 7.8 and HCT of 20.4 percent. Provider documents anemia as the diagnosis being treated. Since the patient received 2 units of PRBCs with HGB of 7.8 and HCT of 20.4, please document acute blood loss anemia.

The fix: Again, the coder writing the query thinks she might know the answer and is not writing to query to be as open-ended as it should be. One revision strategy is multiple choice, Williams said. Just make sure you include "other" among the choices so that the physician may document something other than you suggested. You might also include "undetermined" as a choice if you think the physician could be waiting on the results of diagnostic tests.

The revision: Can the anemia be further specified as:

_________Acute blood loss anemia
_________Chronic blood loss anemia
_________Other:_________________
_________Undetermined

Leading query #3: Dear Dr. Z: The pathology report lists kidney cancer; however, kidney mass is documented in your H/P. Please sign the below stating agreement with kidney cancer.

X_______________________________

The fix: 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.

The revision: Dear Dr. Z: The pathology report lists kidney cancer; however, kidney mass is documented in your H/P. Do you agree with the pathology statement specifying kidney cancer?

_________Yes
_________No
_________Clinically Undetermined
_________Other

Resources:

To learn more about physician queries, see this related article in this month's issue: [https://www.aapc.com/codes/coding-newsletters/my-outpatient-facility-coding-alert/cdi-101-answered-all-your-burning-questions-about-physician-queries-155893-article].

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/.

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