Medical Coding Query format/Sample Coding
query forms
Physician queries have also been used to confirm certain diagnosis codes that have been scrutinized by the government. For example, in some situations a coder might query a physician to determine whether a patient should be diagnosed with the higher-paying gram negative pneumonia (instead of the lower-paying unspecified bacterial pneumonia) or to determine whether the physician’s usage of the vague term "sepsis" should be understood to refer to (higher-paying) septicemia or (lower-paying) urinary tract infection.
1. Example Open-Ended Query
A patient is admitted with pneumonia. The admitting H&P
examination reveals WBC of 14,000; a respiratory rate of 24; a temperature of
102 degrees; heart rate of 120; hypotension; and altered mental status. The
patient is administered an IV antibiotic and IV fluid resuscitation.
Leading: The patient has elevated WBCs, tachycardia, and is given an IV
antibiotic for Pseudomonas cultured from the blood. Are you treating for
sepsis?
Nonleading: Based on your clinical judgment, can you provide a diagnosis that
represents the below-listed clinical indicators?
In this patient admitted with pneumonia, the admitting history and
physical examination reveals the following:
· WBC
14,000
· Respiratory
rate 24
· Temperature
102° F
· Heart
rate 120
· Hypotension
· Altered
mental status
· IV
antibiotic administration
· IV
fluid resuscitation
Please document the condition and the causative organism (if
known) in the medical record.
Source: AHIMA.
“Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA
81, no.5 (May 2010): expanded web version.
2.Example Multiple Choice Query
A patient is admitted for a right hip fracture. The H&P notes
that the patient has a history of chronic congestive heart failure. A recent
echocardiogram showed left ventricular ejection fraction (EF) of 25 percent.
The patient’s home medications include metoprolol XL, lisinopril, and Lasix.
Leading: Please document if you agree the patient has chronic diastolic
heart failure.
Nonleading: It is noted in the impression of the H&P that the patient has
chronic congestive heart failure and a recent echocardiogram noted under the
cardiac review of systems reveals an EF of 25 percent. Can the chronic heart failure
be further specified as:
· Chronic
systolic heart failure____________________
· Chronic
diastolic heart failure___________________
· Chronic
systolic and diastolic heart failure_________
· Some
other type of heart failure _________________
· Undetermined________________________________
Source: AHIMA.
“Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA
81, no.5 (May 2010): expanded web version.
3.Example
Yes/No Queries
Compliant Example 1
Clinical Scenario: A patient is admitted with
cellulitis around a recent operative wound site, and only cellulitis is
documented without any relationship to the recent surgical procedure.
Query: Is the cellulitis due to or the result of the surgical procedure?
Please document your response in the health record or below.
Yes _____________
No ______________
Other ___________
Clinically Undetermined ______________
Name: ___________________ Date:__________
Rationale: This is an example of a yes/no query involving a documented
condition potentially resulting from a procedure.
Compliant Example 2
Clinical scenario: Congestive heart failure is
documented in the final discharge statement in a patient who is noted to have
an echocardiographic interpretation of systolic dysfunction and is maintained
on lisinopril, Lasix, and Lanoxin.
Query: Based on the echocardiographic interpretation of systolic
dysfunction in this patient maintained on lisinopril, Lasix, and Lanoxin can
your documentation of “congestive heart failure” be further specified as systolic
congestive heart failure? Please document your response in the health
record or below.
Yes _____________
No ______________
Other ___________
Clinically Undetermined____________
Name: ___________________ Date:__________
Rationale: This yes/no query provides an example of determining the
specificity of a condition that is documented as an interpretation of an
echocardiogram.
Compliant Example 3
Clinical scenario: During the removal of an
abdominal mass, the surgeon documents, in the description of the operative
procedure, a “serosal injury to the stomach was repaired with interrupted
sutures.”
Query: In the description of the operative procedure a serosal injury to
the stomach was noted and repaired with interrupted sutures. Was this serosal
injury and repair:
A complication of the procedure _____________
Integral to the above procedure _____________
Not clinically significant ____________________
Other ___________
Clinically Undetermined____________
Please document your response in the health record or below
accompanied by clinical substantiation.
Name: ___________________ Date:__________
Rationale: This is an example of a query necessary to determine the clinical
significance of a condition resulting from a procedure.
Non-Compliant Example 1
Clinical scenario: On admission bilateral lower
extremity edema is noted, however, there are no other clinical indicators to
support malnutrition.
Query: Do you agree that the patient’s bilateral lower extremity edema is
diagnostic of malnutrition? Please document your response in the health record
or below.
Yes______________
No ______________
Other ___________
Clinically Undetermined ______________
Name: ___________________ Date:__________
Rationale: Malnutrition is not a further specification of the isolated finding
of a bilateral lower extremity edema. An open-ended or multiple choice query
should be used under this circumstance to ascertain the underlying cause of the
patient’s edema.
Non-Compliant Example 2
Clinical scenario: A patient is admitted with an acute
gastrointestinal bleed, and the hemoglobin drops from 12 g/dL to 7.5 g/dL and
two units of packed red blood cells are transfused. The physician documents
anemia in the final discharge statement.
Query: In this patient admitted with a gastrointestinal bleed and who
underwent a blood transfusion after a drop in the hemoglobin from 12 g/DL on
admission to 7.5 g /dL, can your documentation of anemia be further specified
as an acute blood loss anemia? Please document your response in the health
record or below accompanied by clinical substantiation.
Yes ______________
No ______________
Other ____________
Clinically Undetermined ____________
Name: ___________________ Date:__________
Rationale: In this example, a yes/no query is not appropriate for specifying
the type of anemia. A multiple-choice or open-ended query is a better option.
Non-Compliant Example 3
Clinical Scenario: In the ED, a foley catheter was
inserted for the patient with dysuria and elevated WBCs that was removed two
days after admission. The cultures were positive for E.coli and the progress
note reflect a catheter associated urinary tract infection (CAUTI) and this was
coded. Quality has requested review of the HAC condition to ensure it should be
coded as it does not meet the CDC definition for CAUTI.
Query: The quality department has indicated that your documented
diagnosis of CAUTI does not meet the CDC definition which impacts the Hospital
Acquired condition statistics for your profile as well as the hospital. Does
your patient have a catheter associated urinary tract infection?
Yes ____________
No ______________
Other ___________
Clinically Undetermined _________________
Name: ___________________ Date:__________
Rationale: This query is inappropriate as it explains the impact of the
addition or removal of the diagnosis for the physician and hospital profiles.
This query questions the physician’s clinical judgment which may be more
appropriate in an escalation policy and/or physician education regarding the
CDC definition of CAUTI.
