Physician Query: What is it?
Physician queries have been used by Health Information Management (HIM) and Clinical Documentation Improvement (CDI) professionals in hospitals, but physician queries can be used in any setting.
A physician query is a communication between the facility and physician to improve accuracy of documentation for more specific coding and to enhance care planning efforts. The query is usually conducted in a written format with a question or questions to the physician to obtain additional and/or clarifying documentation. A physician query may be necessary when clarity regarding a resident’s clinical condition isn’t clear, the clinical information is conflicting, is vague, non-specific, or when clinical information may appear to be missing. Obtaining clarity to accurately portray the complete picture of the resident’s condition is necessary to support all aspects of the resident’s care. Not every discrepancy or documentation issue requires a query. The facility must determine if the resident’s current health record documentation requires clarification or additional information.
A query should include brief clinical findings as documented in the record and clarify clinical relationship between findings and diagnosis implied by clinical management of the resident. To be compliant with physician queries, avoid leading the physician to a desired response. The query should be brief and to the point; three to four sentences maximum.
The Association of Clinical Documentation Integrity Specialists (acdis) guidance states that queries should be:
- Clear and concise;
- Contain clinical indicators from the health record;
- Present only the facts identifying why the clarification is required;
- Never include impact on reimbursement or quality measures.
The query form can/should be used to the extent it provides clarification and is consistent with other medical record documentation. A query can be verbal, written, or electronic, but regardless of the method, the query must comply with non-leading requests and permit the physician to be able to provide an unbiased response when providing/clarifying a specific diagnosis or procedure. In other words, the query should not include leading questions to lead the physician toward any certain diagnosis or suggestion of a diagnosis. In addition, the query should be phrased so that the physician is allowed to specify the correct diagnosis. It should not indicate the financial impact of the response. Furthermore, the physician query should never be completed in order to increase reimbursement and should not question the physician’s professional judgment. The query form should not be designed so that the only thing required is a signature.
The American Health Information Management Association (AHIMA) has a great article, Guidelines for Achieving a Compliant Query Practice, that provides a deep dive in to the physician query process.
Director of Compliance and Regulatory Strategy
Other source document: The Physician Query Process and Compliance Issues HCCA