The key to getting the medical record clarified and the information required to code properly is learning how to draft an effective, non-leading query to the physician.
The Physician Queries Handbook is the authoritative source for defining policies, procedures, and best practices for physician queries.
Coauthored by a physician, and CDI professionals with nursing, coding, and HIM backgrounds, the Physician Queries Handbook provides practical, tips and best practices for querying physicians on a concurrent or retrospective basis. It also presents strategies on how to develop a query policy and procedure that takes into account the many different facility-specific topics that directors and managers must understand.
Turn words into actions
Although Coding Clinic, AHIMA, and the ICD-9-CM Official Guidelines for Coding and Reporting provide guidance related to query policies and procedures, there are still a lot of gray areas for which hospitals must account, such as:
Who should leave queries?
What is a leading query?
How long should staff expect to wait for a query response?
How should hospitals deal with reluctant physicians?
Take a look at the topics covered in the Physician Queries Handbook:Regulatory impact on physician queries
ICD-9-CM, Coding Clinic, MSDRGs, AHIMA, CMS, and OIG clarifications
CDI program basics and the query process
Enlisting internal facility support
Developing query roles
Defining CDI program organizational structure
Query process infrastructure
Prospective, concurrent, and retrospective queries
How to construct physician queries
Verbal vs. written queries
Coder/CDI productivity and quality
Joint Commission rules
Medical staff procedures
ACDIS physician query benchmarking survey
AHIMA physician query practice brief
ICD-9-CM query rules
Coding Clinic references
Sample query forms
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