Q: A consultant has advised us to code only diagnoses listed on the discharge summary. If the diagnosis is not on the discharge summary, the consultant instructed us to query the physician. How do other facilities handle these scenarios?
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 »
Q: Recently, a consultant suggested that if we asked the physician to clarify systolic/diastolic on a query form for congestive heart failure (CHF) it might be construed as leading the physician if there had been no previous mention of...Read More »
Q: Whenever we get a trauma patient, it’s either very easy to get to the multiple significant trauma (MST) major diagnostic category (MDC), or it becomes a real challenge, especially taking into account the rules pertaining to two body sites...Read More »
Q: Our CDI specialists call the physicians when queries have not been answered. Sometimes the physician will give us an answer over the phone. I’m wondering if that’s okay. Can our CDI staff, who are registered nurses, take the verbal...Read More »
Q: Is systemic inflammatory response syndrome (SIRS) an inherent part of an infection? For example, when a patient comes in with pneumonia, and clinical indicators are present for SIRS but the physician did not specifically write SIRS, should coders or CDI specialists query physicians?...Read More »
Q: If a CDI specialist or coder queries a physician and the response is written on the query letter is it legal to code from this? Or should the physician only respond in his or her progress note or discharge summary? Also, can the facility...Read More »
