HCPro, JustCoding Inpatient - 2015 Issue 10 (March)
Get back to query basics
March 11th, 2015
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Article Overview
This article is a refresher on physician query practices for CDI and coding professionals. It summarizes the roles of AHIMA, ACDIS, CMS, AHA, Coding Clinic, and the Official Guidelines for Coding and Reporting, and it discusses broad categories of query guidance, including compliant query principles, query format options, and situations in which clarification may be needed. It is relevant for coders, CDI specialists, and compliance staff who want to understand how major guidance sources shape query practice.
Why This Topic Matters
Query practices affect documentation quality, coding accuracy, and compliance. Understanding the hierarchy of guidance and the general boundaries of compliant querying helps CDI and coding teams align with current standards.
Article Sections
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Introduction
Introduces common misconceptions about query practices and frames the article as a refresher on compliant physician query guidance.
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All guidance is not equal
Reviews the major organizations and publications that influence coding and query guidance, including the broad relationship between official coding guidance and specialty association advice.
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New rules differ from old rules
Summarizes how newer practice brief guidance updated earlier query concepts, including query format considerations and circumstances in which clarification may be appropriate.
What You Will Learn
- How query guidance is organized across major coding and CDI organizations
- The general role of official coding publications in query practice
- Broad categories of query situations discussed in compliant query guidance
- How query format choices are presented in current physician query guidance
- Why hierarchy and consistency matter in query and documentation review
Who Should Read This
- Medical coders
- CDI specialists
- Coding compliance staff
- Health information management professionals
- Physicians involved in documentation clarification
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