Q:Our program does not typically include query information as part of the medical record. If the physician responds to a faxed query, we scan the fax into our electronic record. However, we resolve most queries in person or through a secure messaging system in our EMR (...Read More »
Q:I have heard that some facilities have seen their number of generated queries actually increasing rather than decreasing over time. Generally, we hope that by improving the documentation concurrently, we would decrease the need to ask the questions retrospectively. If...Read More »
It’s not enough to know whether heart failure is systolic or diastolic. Congestive heart failure (CHF), for example, isn’t an inherent component of systolic and diastolic heart failure, according to Coding Clinic, fourth quarter 2004. That means CHF, when present, requires a second code...Read More »
Q: AHIMA’s 2008 practice brief, “Managing an Effective Query Process,” appears to allow the initiation of post-bill queries as a result of an audit or other internal monitor. Historically we believed that a query completed after the initial bill was not permitted to be submitted for...Read More »
Congestive heart failure (CHF) is one example of a condition for which coders and CDI specialists should understand clinical indicators before querying physicians, says Lynne Spryszak, RN, CCDS, CPC-A, a CDI educator at HCPro, Inc., in Marblehead, MA.
Despite some misconceptions to the contrary, a coder may report angina, unstable (411.1) if a physician documents any of the following diagnoses and a query is not required:
Many CDI specialists struggle with the problem of educating physicians about documentation requirements. Typical trouble areas include acute kidney failure versus acute renal failure or acute renal injury. While some CDI managers have a chance to educate new physician staff in one-on-one...Read More »
