Health Information Management

Tips to help improve physician queries

HIM-HIPAA Insider, April 5, 2011

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Physician queries are a predictable part of any coder's job. Coders may pose hundreds—even thousands—of queries throughout their careers. One thing remains constant; there's always room for improvement. How can coders write more effective queries and essentially get more bang for their buck? 

  • Keep it short and sweet. "I think what grabs a physician's attention is a query that's clear, fact-based, and direct," says Gail B. Marini, RN, MM, CCS, LNC, manager of clinical documentation at South Shore Hospital in Weymouth, MA. "I think when it gets wordy, or it looks as though there's a paragraph to read, the query is often ignored."
  • Make it obvious. Queries should be easy to identify (e.g., use colored paper rather than white ­paper) and should clearly reference a tab in the record that points to the exact progress note and date for which the query is relevant, says Marini.
  • Send follow-up e-mail. "My staff members e-mail physicians anytime they enter a query on the chart. This seems to work reasonably well," says Jean Stone, RHIT, CCS, coding manager at Lucile Packard Children's Hospital at Stanford in Palo Alto, CA.
Editor’s note: To read more, access this article in the April issue of Briefings on Coding Compliance Strategies.



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