Radiology Coding Alert

Learn how to effectively query a provider for information.

Not every patient record or radiology report is complete, and your ability to effectively communicate with physicians is critical to querying them for the missing information.

Why? Because if you’re too intimidated to request the missing documentation — or you don’t get the answers you need — the trepidation will be seen in your coding selections.

Use this guidance to understand the query process and help maintain open communication with the providers you work with.

Grasp the Goal of Querying

From time to time, you may find yourself needing clarification about a physician’s documentation before you feel confident figuring out the appropriate ICD-10-CM and CPT^® codes. Seeking clarification by querying the physician helps you understand what the provider is attempting to tell you, so the clinical picture of the encounter and the patient’s condition is complete and accurate.

What’s more, “if you can establish a relationship with your provider, you’ve done 75 percent of the work in coding and querying,” advised Emily Schmidt Barnette, CPC, CPC-P, CDEO, CPB, CPMA, CRC, CPC-I, during her HEALTHCON 2023 presentation “Communicating with Providers.” Becoming more comfortable with querying physicians will give your practice a boost in improving your clinical documentation and having a higher rate of successfully paid claims.

Keep in mind, queries should not:

• Question a provider’s clinical judgment
• Lead the provider to answer in a certain way
• Include the impact on revenue

“The goal of the query is to clarify information in the medical record, improving or increasing data integrity,” says Leonta Williams, MBA, RHIA, CPC, CPCO, CRC, CEMC, CHONC, CCS, CCDS, senior director of education at AAPC. “It should never be about maximizing revenue. If you do all things appropriately or correctly, that revenue maximization will come without you having to risk any compliance issues within your facility.”

Know the Common Reasons To Query

You might have to query your provider for any of the reasons below:

• Legibility: If you as the coder cannot read and input the information, you will need to query.
• Completeness: At times, there may be clinical indicators such as diagnostic labs, imaging, pathology, or prescribed medications found within the patient’s medical record. If they or other elements of medical care are not documented by the provider, you should query.
• Clarity: Oftentimes, signs and symptoms may be reported or present in the medical record, but your provider hasn’t established a definitive condition, which could be a reason to query.
• Consistency: Consistency involves variances within the medical record. If there are any inconsistencies in the notes from the beginning to the end of the encounter, you need to query.
• Precision: Although ICD-10-CM gives us an opportunity for increased specificity in code assignment, to assign codes to the highest level of specificity, you must have matching and supporting documentation.

Understand How To Present a Query

Queries may be written or verbal and generated in one or more of the following ways:

• Concurrent (while the patient is still under treatment)
• Retrospective (post-encounter)

“The technique of writing a query is critical in ensuring clear and precise communication to a provider. Make sure that the question you are asking makes sense with the information you are providing as support. I like to use ‘specify and clarify’ in my queries, but any language will work provided the doctor understands the query,” says Vida Rothstein, BSTM, HIT, CCS, CCS-P, RHIT, AAPC inpatient auditor for Audit Service Group in South Bend, Indiana.

All queries should then follow the same format, whether written, emailed, or delivered over the phone, stressed Schmidt Barnette. They should:

• Be clear, concise, and non-leading;
• Contain simple and direct language;
• Itemize the clinical indicators or clues from the health record; and
• Contain all the patient’s identifying information such as name and date of service, as well as clinical findings with supporting documentation that results in a specific question for the provider.

“It’s important to avoid leading the provider with your language. “You want to avoid saying things like, ‘Please document if you agree that the patient has ____,’ and instead ask questions that will help you narrow down the correct coding,” Schmidt Barnette suggested. You should ask more specific questions like, “Based on your clinical judgment, can you provide a diagnosis that represents the below-listed indicators?” to get to the correct diagnosis.

It’s essential to use compliant query templates for written and emailed queries, as Schmidt Barnette emphasized during the presentation. This ensures consistency and accuracy in documentation across the entire office.

Important: Queries should be a part of the patient’s permanent medical record, and the answers to the queries help support your code assignments.

Consider These Generic Queries

Suppose you need to query a provider regarding a recent procedure. Here are a few examples of questions you might want to ask:

• Can you provide more detail about the specific procedure that was performed?
• Where was the procedure performed?
• Can you clarify the approach that was used during the procedure?
• Were there any complications during or after the procedure that should be documented?
• Were any additional procedures or treatments performed during the same encounter that should be documented?
• Can you provide documentation of the medical necessity and any supporting diagnostic tests or imaging studies?

In short, “educating the provider that there are certain circumstances and certain terminologies helps reduce what I call physician query fatigue,” Rothstein says.

Aim for Mutual Respect

It’s important to keep in mind that tone is so much of communication. “Always be respectful of their time and highlight the mutual benefits of coding correctly … and don’t lecture. Be personable, don’t be a coder, don’t be a robot who just spits out coding guidelines, it just makes the whole thing easier,” Schmidt Barnette said. She reminded her audience that both the coder and the practitioner bring different skill sets to the table that are mutually dependent upon each other and stressed the importance of encouraging teamwork. Being open to listening, asking meaningful questions, and understanding the value of each other’s time is also key to successfully querying the practitioner.