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Properly coded clinical documentation is one of the cornerstones of an effective healthcare practice, and that’s why it’s often one of the most substantial parts of compliance training for institutions. In the best of circumstances, every medical note is clear, coding is straightforward, and there’s no need for additional clarity — which is often not the case. A physician query can result from improper, incomplete, or insufficient clinical documentation that requires increased clarity.
What Is a Physician Query?
A physician query is a request made by a coder for additional information from the physician. This additional information is then used to determine the best way of coding the clinical services provided for insurance purposes. Sometimes, the initial discrepancy and request for more information can lead to friction between clinicians and medical coders, when really, both parties are just doing their job — physicians who are focused on providing accessible patient care and coders who need to have a thorough understanding of the services provided in order to substantiate insurance reimbursement.
Physician queries are a critical way for coders to provide a clearer picture of any documentation related to a health record. Yet, they must be done correctly, not only for clarity, but to maintain consistency within an organization and compliance with outside governing entities. Here are just some of the reasons why a physician query is essential to accurate coding:
- Determining illness severity and risk of mortality
- Tracking cases and diagnoses
- Managing denials and reducing the need for audits
- Substantiating insurance (payer) reimbursement for medical services
Additionally, the life of a physician query doesn’t end once the communication between a coder and physician stops. Queries must be tracked so that accurate documentation can be recorded and referenced if needed.
Why Do Physician Queries Matter?
Medical coding ensures that a healthcare institution can get fairly compensated for the care they provide. With healthcare costs on the rise and insurance companies becoming increasingly strict about what requirements must be met before paying providers, it’s now more important than ever to document all aspects surrounding a diagnosis in order to receive compensation.
It’s not unusual for a physician to view a query as a challenge to their clinical judgment. Thankfully, the frustration is usually just a mere misunderstanding, easily rectified with some clarification on how and why a query would be initiated.
When a Physician Query Is Necessary
The outcome of a physician query is critical because it can change a patient’s overall treatment plan when it comes time to bill for the services received from a clinician. However, under no circumstance is a coder’s query a challenge to the physician’s judgment. Treating patients is a highly individualized, unique, and complex process that can sometimes result in disorganized or imprecise documentation of the symptoms that led to a diagnosis. Here are four situations where further clarity regarding treatment would be needed from a physician:
- Diagnosis performed without primary clinical validation
- Unspecific clinical indicators
- Conflicting or inconsistent information regarding treatment
- Diagnostics or treatments that do not align with a particular condition
- Gaps in notable patient progress or regress
If a coder requests additional information, physicians sometimes respond with a detailed clinical description to defend the position, resulting in lost time and increased frustration as two members of the organization work to fulfill their respective roles.
How a Physician Is Queried
There are multiple components of a straightforward and compliant physician query. All queries to physicians typically contain the following information:
- Provider name
- Site name
- Member (patient) name
- Member (patient) DOB
- Date of Service
In addition to the above information, queries should be clear and concise, with instructions on how to resolve any pending questions about coding, without leading the physician to a particular response or desired outcome. A physician query should also be coordinated directly with the provider, including an agreed-upon timeframe and structure for any pending inquiries.
How Can Providers Reduce Physician Queries?
Document, document, document. Proper and thorough documentation of all clinical indicators, diagnoses, and reasoning behind any patient services or treatments rendered, is required of any healthcare provider and can reduce physician queries. Regulatory audits are inevitable and without detailing these components in clinical documentation, the provider puts themselves and their organization at risk for noncompliance and fraudulent insurance reimbursement, leading to fines, fees, and lawsuits.
Knowing the standards and importance of accurate health documentation is key to not only reducing physician queries, but also providing high-quality, goal-oriented, and evidence-based patient care.
Using Technology To Maintain Documentation
An all-in-one healthcare compliance solution provides a centralized location for all documentation, policies, and reporting to simplify processes. Full-cycle policy management ensures physicians and coders have access to policies and procedures anytime there is a question about regulations or the organization’s expectations. Electronic signing and acknowledgment ensure employees are aware of expectations related to fraud.
Ready to take your healthcare compliance to the next level? Contact the MedTrainer team today!