Radiology Coding Alert

Learn how to set up an efficient, working system of communication.

The radiology specialty presents numerous challenges involving clinical documentation improvement (CDI) that other medical specialties don’t typically face. While coders of nearly every medical specialty need access to their physicians for queries and addendums, provider accessibility is an increasingly problematic area when it comes to radiology.

With that said, there are some general rules that coders and practice managers of all specialties should follow in order to improve communication methods between the coding/ billing team and the interpreting radiologist. Knowing when and how to properly query your radiologist can go a long way in not only getting the answers you need, but also improving documentation practices for the future.

Read on to maximize your knowledge and efficiency with these expert tips for writing queries and analyzing physicians’ answers.

Understand What Constitutes a Query

You write a query when something about the physician’s documentation is confusing, conflicting, or lacking in detail. Before you submit a query, make sure you’ve brushed up enough on your clinical skills to understand what you’re reading, stresses Leonta Williams, RHIT, CPCO, CPC, CEMC, CHONC, CCD, CCDS. If you submit a query about accessible clinical information you should know, “that lessens your credibility” in your practice, says Williams.

Send a query when the documentation seems to be missing a key fact. For example, if the clinical indication is ambiguous or doesn’t include a clear billable diagnosis.

Or, the clinical indication, findings, or impression may contain what appears to be conflicting information.

“A query is a routine communication and education tool used to advocate complete and compliant documentation,” according to the American Health Information Management Association (AHIMA)’s “2019 update: Guidelines for achieving a compliant query practice” (URL: https://acdis.org/articles/2019-update-guidelines-achieving-compliant-query-practice).

“The desired outcome is an update of the health record to better reflect the provider’s intent and clinical thought process,” AHIMA adds. A proper query ensures that appropriate documentation appears in the dictation or surgical report.

Note CMS Guidelines for Queries

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 the Centers for Medicare & Medicaid Services (CMS) guidelines to remain compliant. Never mention dollar amounts in your queries, Williams stresses.

Queries Should Be in Writing, With These Elements

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

The form should list the patient’s name, date of service, accession number, provider’s name, name and contact of the individual sending the query, date of query, and the statement of the issue in the form of a question or request for additional information. Williams advises that you word your query carefully so that you “don’t box the provider in. Steer clear of ‘leading’ queries that give providers only one way to answer the question.”

Queries should be “non-leading,” even if you think you know what the provider meant to document. You might ask for an addendum or even go as far as providing multiple-choice options that include an “other” option to help the provider articulate their thinking in the medical note. Pay close attention to the headings you use for queries, Williams cautions, because sometimes headings can cause the query to be leading.

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 1000ml of normal saline administered.”

Look to Education, Workflow

Because queries take up staff and provider time, they can cost a practice money if queries cover the same topics over and over again. Plus, they can feel like a headache.

However, most providers dislike queries, too, so the revenue department and the coding team should communicate that the ultimate goal of your query program is to reduce the need for queries in the first place. One tactic is to tie documentation to how it impacts the patient—as in what happens to the patient if there is good documentation versus bad, Williams says. “That usually helps the provider understand,” she explains.

Williams recommends practices set up a query tracking form in Excel that records:

• Most common reasons for queries;
• Providers with a high query percentage;
• Providers with a low query rate;
• Query themes that reoccur repeatedly: Where might you focus your physician education efforts?;
• Provider response turn-around time; and
• Provider agreement rate: “Be wary of the provider who agrees with the coder’s query 100 percent of the time,” Williams cautions.

Query tracking can help identify patterns and help improve documentation habits. As you build your CDI program, you might enlist the physician who is queried least often to be your CDI champion. If you and the doctors work together, you’ll see a return on investment resulting in better documentation, less back-and-forth time wasted, faster claims submissions, reduced denials, and fewer appeals.