Query Writing in Clinical Data Management

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					DEPARTMENT: Health Information                   POLICY DESCRIPTION: Query Documentation
Management Services                              for Inpatient Services
PAGE: 1 of 7                                     REPLACES POLICY DATED: April 1, 2001
APPROVED: March 6, 2001                          RETIRED:
EFFECTIVE DATE: April 1, 2001                    REFERENCE NUMBER: HIM.COD.012


SCOPE: All personnel responsible for performing, supervising or monitoring coding of inpatient
services including, but not limited to:

Facility Health Information Management                   Administration
Internal Audit & Consulting Services                     Physician Advisors
Corporate Health Information Management ServicesExternal Coding Contractors
Case Management/Quality Resource Management              Ethics and Compliance Officer
Business Office/Central Business Office/Medicare Service Center/Financial Service
Center/Revenue Service Center

This policy applies to queries initiated for all inpatient services provided in Company-affiliated
facilities (acute care, freestanding psychiatric, and rehabilitation) unless otherwise indicated in a
separate policy. For queries specific to the assignment of ICD-9-CM code of 482.83 (Pneumonia
due to other gram-negative bacteria), refer to Company Policy Memorandum entitled Special
Coding Practices on ICD-9-CM Code 482.83 dated October 20, 2000. For outpatient services,
refer to the Coding Documentation for Outpatient Services Policy, HIM.COD.002. For skilled
nursing services, refer to the Coding Documentation for Skilled Nursing Facilities/Units Policy,
HIM.COD.010.

PURPOSE: The purpose of this policy is to define when a query will be initiated and outline the
appropriate query processes to be used. Appropriate querying will improve the accuracy, integrity
and quality of patient data; minimize variation in the query process; and improve the quality of the
physician documentation within the body of the medical record to support code assignments. A
query is an established mechanism of communication between coders and physicians to clarify
ambiguous, incomplete or conflicting documentation in the medical record in order to facilitate
complete, accurate and consistent coding practices. The Company has developed six (6) approved
standardized query forms. The selection of the appropriate standardized form will be determined
based on the type of query being initiated. Two of the standardized query forms are to be used for
pneumonia; three of the query forms are to be used for sepsis; and one query form will provide a
template to be used for all other queries. The approved and required standardized query forms are
attached to this policy (see Attachments A-F).

POLICY: When the documentation necessary to assign an ICD-9-CM code for an inpatient case is
not clearly stated within the medical record or is conflicting or ambiguous, a query is required
(unless otherwise indicated in a separate Company Policy Memorandum). Company facilities will
follow the Official Guidelines for Coding and Reporting diagnoses and procedures published in
AHA Coding Clinic for ICD-9-CM, Second Quarter, 1990 and Fourth Quarter, 1996 and/or the
4/2001
DEPARTMENT: Health Information                 POLICY DESCRIPTION: Query Documentation
Management Services                            for Inpatient Services
PAGE: 2 of 7                                   REPLACES POLICY DATED: April 1, 2001
APPROVED: March 6, 2001                        RETIRED:
EFFECTIVE DATE: April 1, 2001                  REFERENCE NUMBER: HIM.COD.012

most current AHA Coding Clinic for ICD-9-CM Guidelines.

PROCEDURE:
1. The Query Process
   The coder is required to query the physician participating in the care of the patient once a
   diagnosis or procedure has been determined to meet the AHA Coding Clinic for ICD-9-CM
   official coding guidelines for reporting but has not been clearly stated within the medical
   record, or when conflicting or ambiguous documentation is present. Implementation
   guidelines provide additional guidance on appropriate queries and are located on the
   Company’s Intranet site on the Health Information Management Services page.
   a. Query Documentation
        The query documentation must include:
              (1)    the name of the individual submitting the query;
              (2)    the patient’s name;
              (3)    the patient’s medical record number;
              (4)    the patient’s account number;
              (5)    the date the query was submitted;
              (6)    an itemization of clinical findings pertinent to the condition/procedure in
                     question including the source document(s) from the medical record supporting
                     the query; and
              (7)    the statement of the issue in the form of a question.
   b. Query Format
        i) If a query is necessary to clarify ambiguous or conflicting documentation in the
              medical record in order to facilitate complete, accurate and consistent coding
              practices, the query must be documented on one of the approved separate query
              forms.
        ii)      The approved query forms include all of the required query elements and are
              attached to this policy. (See Attachments A-F).
        iii)     The selection of the approved query form will be determined based upon the
              specific type of query that is being initiated. The determination of the appropriate
              method or approach to the query must be based on the following:
              (1) Pneumonia:
                   i. If the physician has documented pneumonia in the medical record and there
                        is a positive sputum culture, use query form A to determine if further
                        specificity related to the type of pneumonia can be obtained.
                   ii. If the physician has documented pneumonia in the medical record and there
                        is not a positive sputum culture, do not query. However, if there are
                        extensive clinical indications of aspiration pneumonia, see iii immediately
4/2001
DEPARTMENT: Health Information                   POLICY DESCRIPTION: Query Documentation
Management Services                              for Inpatient Services
PAGE: 3 of 7                                     REPLACES POLICY DATED: April 1, 2001
APPROVED: March 6, 2001                          RETIRED:
EFFECTIVE DATE: April 1, 2001                    REFERENCE NUMBER: HIM.COD.012

                       below.
                  iii. If there are extensive clinical indications of aspiration pneumonia, use query
                       form B as a means to clarify if aspiration pneumonia is or is not present. By
                       extensive, it is meant that the physician has substantially described
                       aspiration pneumonia but has not made the specific or particular diagnosis.
                  iv. If the purpose of the query is not included as one of the above conditions,
                       use query form F.
              (2)   Sepsis
                  i. If the physician has recorded the diagnosis of sepsis and there is no positive
                       blood culture, a query is not necessary and sepsis should be reported based
                       on physician documentation.
                  ii. If the physician has documented sepsis in the medical record and there is a
                       positive blood culture, use query form C to determine if further specificity
                       related to the type of sepsis can be obtained.
                  iii. If the physician has documented a localized infection (e.g., urinary tract
                       infection, cellulitis) and there are extensive clinical indicators of a
                       generalized sepsis, use query form D. By extensive, it is meant that the
                       physician has substantially described the clinical condition of sepsis, but has
                       not made the specific or particular diagnosis.
                  iv. If the physician has documented a localized infection (e.g., urinary tract
                       infection, cellulitis) and there are not extensive clinical indicators of a
                       generalized sepsis, a query is not warranted and the code assignment should
                       report the highest level of specificity based upon the physician
                       documentation in the medical record.
                  v. If the physician has documented urosepsis and there are extensive clinical
                       indicators of a generalized sepsis and clarification is needed to determine
                       whether this is a localized urinary tract infection or a generalized sepsis, use
                       query form E.
                  vi. If the purpose of the query is not included as one of the above conditions,
                       use query form F.
              (3)   Any Other Queries
                    For any other query that is required to clarify ambiguous, incomplete or
                    conflicting information contained in the medical record, use query form F.


  c.      Maintenance of the Query Form
         The coding query process can be conducted and documented on a concurrent or
         retrospective basis.
4/2001
DEPARTMENT: Health Information                POLICY DESCRIPTION: Query Documentation
Management Services                           for Inpatient Services
PAGE: 4 of 7                                  REPLACES POLICY DATED: April 1, 2001
APPROVED: March 6, 2001                       RETIRED:
EFFECTIVE DATE: April 1, 2001                 REFERENCE NUMBER: HIM.COD.012

           (1)     Concurrent - If the sole purpose of the concurrent process is to clarify
                   documentation for the purpose of final code assignment, the query may be
                   posed verbally or in writing; the query (whether verbal or in writing) must be
                   documented on one of the approved and required standardized query forms;
                   and maintained in the body of the medical record. If the sole purpose of the
                   concurrent process is not for clarifying ambiguous or conflicting
                   documentation for coding purposes, e.g., certification for insurance purposes,
                   follow the applicable facility policies regarding the maintenance of the
                   concurrent information.
           (2)     Retrospective – The query process may be posed verbally or in writing. If the
                   coding query process is conducted (whether verbal or in writing), it must be
                   documented on one of the approved and required standardized query forms
                   and maintained in the body of the medical record.
  d. Query Response
     The query response from the physician that will be used to support a code assignment must
     be documented by the physician in the body of the traditional medical record and/or, at a
     minimum, on the query form (which must be kept as a permanent part of the medical
     record). The traditional medical record is defined as the customary forms, based on the
     patient type, which are contained in the medical record to furnish documentary evidence of
     the course of the patient’s illness and treatment during each hospital admission. If the
     patient has been discharged, the response to a (retrospective) query must be documented in
     the body of the medical record by the physician and be signed and dated with the date that
     the information is added to the medical record. The response must in the form of a late
     entry progress note, an addendum to a dictated report (e.g., discharge summary, H&P,
     consultation), or as an inclusion in the dictated discharge summary or, at a minimum, the
     response must be on one of the six approved and required coding query forms. If the local
     Peer Review Organization (PRO) is requiring the query response to be documented in the
     body of the traditional medical record, the response must be in the form of a late entry
     progress note, an addendum to a dictated report (e.g., discharge summary, H&P,
     consultation), or as an inclusion in the dictated discharge summary.
  e. Billing and Delinquent Record Count for a Chart with a Query
      i) Any chart awaiting a response to a query must not be final abstracted (final billed)
           until the physician’s response is documented on the query form and/or in the body of
           the traditional medical record or the physician has responded that no addition to or
           clarification of the medical record is necessary.
      ii) Any query requiring a physician response must be included in the incomplete and
           delinquent record count until the response is received and documented in the
           appropriate place in the medical record or the physician has responded that no
4/2001
DEPARTMENT: Health Information                 POLICY DESCRIPTION: Query Documentation
Management Services                            for Inpatient Services
PAGE: 5 of 7                                   REPLACES POLICY DATED: April 1, 2001
APPROVED: March 6, 2001                        RETIRED:
EFFECTIVE DATE: April 1, 2001                  REFERENCE NUMBER: HIM.COD.012

            addition to or clarification of the medical record is necessary. This requirement must
            be reflected in the medical staff bylaws or rules and regulations.
   f. Medical Staff Approval Process
      If medical staff approval is necessary, the Health Information Management (HIM) Director
      must submit the standardized query forms for approval following the process outlined in
      hospital policy or medical staff bylaws or rules and regulations for adding forms to the
      medical record.
   g. Query Education and Tracking
       i) All facilities should educate their physicians on the importance of concurrent
            documentation within the body of the medical record to support complete, accurate
            and consistent coding.
       ii) Communication should be provided to the medical staff that coders or representatives
            of HIM and/or Quality Resource Management will query physicians when there are
            questions regarding documentation for code assignment.
       iii) Communication must clarify that the query will be documented in writing and that the
            physician response must be included on the query form and/or within the body of the
            traditional medical record.
       iv) Queries must be tracked in order to facilitate improved documentation and
            appropriate release of the claim for billing purposes.
       v) Administration and medical staff leadership must support this process to ensure its
            success.

2. Query Guidelines
   In order to achieve consistency in the coding of diagnoses and procedures, coders must:
   a. Follow procedures that result in complete, accurate and consistent coding and accurately
       represent the patient’s diagnoses and procedures for the relevant episode of care;
   b. Adhere to all official coding guidelines as stated in this policy;
   c. Assess physician documentation to ensure that it supports the diagnosis and procedure
       codes selected;
   d. Consult physician for clarification and additional documentation prior to final code
       assignment when there is conflicting or ambiguous data in the medical record;
   e. Not use the word “possible” in a query unless specified in the physician documentation;
   f. Assist and educate physicians and other clinicians by advocating proper documentation
       practices, further specificity, resequencing or inclusion of diagnoses or procedures when
       needed to more accurately reflect the patient’s episode of care;
   g. Follow the procedures as outlined in this policy to document an appropriate query; and
   h. Query the physician if the physician has substantially described a clinical condition but has
       not made a diagnosis. The query must be documented on the appropriate approved and
4/2001
DEPARTMENT: Health Information                   POLICY DESCRIPTION: Query Documentation
Management Services                              for Inpatient Services
PAGE: 6 of 7                                     REPLACES POLICY DATED: April 1, 2001
APPROVED: March 6, 2001                          RETIRED:
EFFECTIVE DATE: April 1, 2001                    REFERENCE NUMBER: HIM.COD.012

         required query form attached to this policy.

3. Facility Query Compliance Monitoring
   Internal facility-directed (which includes coding supervisors) or certified external vendor
   (which excludes Corporate HIMS, Independent Review Organization and Internal Audit &
   Consulting Services) coding quality reviews must be completed on a regular basis by each
   facility.
   a. Reviews must include review of the query process to determine query appropriateness and
       accurate code assignment with comparison to the UB-92 claim form to determine accurate
       billing.
   b. Findings from these reviews must be utilized to improve the query process, coding and
       medical record documentation practices and for coder and physician education, as
       appropriate.

4. Company-Wide Query Compliance Monitoring
   Compliance with this policy will be monitored by the Corporate Health Information
   Management Services Department.
   a. It is the responsibility of each facility’s administration to ensure that this policy is applied
      by all individuals involved in the coding and querying of medical record documentation in
      inpatient records.
   b. Employees who have questions about a decision based on this policy or wish to discuss an
      activity observed related to application of this policy should discuss these situations with
      their immediate supervisor to resolve the situation.
   c. All day-to-day operational issues should be handled locally; however, if confidential advice
      is needed or an employee wishes to report an activity that conflicts with this policy and is
      not comfortable speaking with the supervisor, employees may call the toll-free Ethics Line
      at 1-800-455-1996.

For any questions regarding this policy, please contact the HIMS P&P Helpline at 1-800-690-0919
or by the e-mail address: HIMS P&P Helpline.


REFERENCES:

Coding Clinic for ICD-9-CM is the official publication of ICD-9-CM coding guidelines and advice
as designated by four cooperating parties: American Hospital Association (AHA), American
Health Information Management Association (AHIMA), Health Care Finance Administration
(HCFA), and the National Center for Health Statistics (NCHS).
4/2001
DEPARTMENT: Health Information               POLICY DESCRIPTION: Query Documentation
Management Services                          for Inpatient Services
PAGE: 7 of 7                                 REPLACES POLICY DATED: April 1, 2001
APPROVED: March 6, 2001                      RETIRED:
EFFECTIVE DATE: April 1, 2001                REFERENCE NUMBER: HIM.COD.012


Practice Brief on Data Quality, American Health Information Management Association
(AHIMA), Chicago, Illinois, February 1996.

AHIMA Standards of Ethical Coding, American Health Information Management Association
(AHIMA), Chicago, Illinois, Revised December 1999.

Health Information Management Compliance, A Model Program for Healthcare Organizations,
Sue Prophet, Chicago, Illinois, 2000 Edition.

HCFA memorandum to the Peer Review Organization entitled “Use of the Physician Query
Forms” dated January 22, 2001.

HCFA memorandum to the Peer Review Organizations entitled “Use of Physician Query Form”
with Policy Clarification of Temporary Suspension of January 22, 2001, dated March 21, 2001.




4/2001
Query Form A – Pneumonia

                                         PNEUMONIA
                                    PHYSICIAN QUERY FORM
                                  THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                       Please return this form by fax to:
Dear Dr. ____________________________:                                          XXX-XXX-XXXX


In responding to this query, please exercise your independent professional judgment. The fact that a question is asked
does not imply that any particular answer is desired or expected. We greatly appreciate your clarification on this issue.

Coder’s Name: _________________________ Coder’s Phone #: _____________________________

Patient Name: ________________________________________________________________

Admit Date: _____________________ Discharge Date: ___________________

MR#:    ___________________ Acct #: ______________________________________


The medical record reflects the diagnosis of pneumonia in the (progress notes, dictated report, history and
physical)__________________________________________________________________________
and the sputum culture shows (specify organism identified in the sputum culture(s) ________________
________________________________________________________________________________.


Please respond to the following questions and take the appropriate action based on your response:

Based on the above information, can you identify the specific organism responsible for this
patient’s pneumonia?

                        Yes – [If yes, please document the specific type of organism that was treated and was responsible for the
                        pneumonia in the space provided below and/or in the medical record (progress notes, dictated report or an
                        addendum to a dictated report)].

                        ______________________________________


                        _______________________________                     _________________________
                        PHYSICIAN SIGNATURE                                     DATE


                        No- [If no, please initial in or check the box, and sign and date below. This form will need to be maintained with
                        the medical record.]



                        Unable to determine – [If so, please initial in or check the box, and sign and date below. This form will need to
                        be maintained with the medical record. ]


                        _______________________________                     _________________________
                        PHYSICIAN SIGNATURE                                     DATE




                                                                                                           Attachment to HIM.COD.012
Query Form B – Aspiration Pneumonia
                              ASPIRATION PNEUMONIA
                              PHYSICIAN QUERY FORM
                            THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                           Please return this form by fax to:
Dear Dr. ____________________________:                                              XXX-XXX-XXXX


In responding to this query, please exercise your independent professional judgment. The fact that a
question is asked does not imply that any particular answer is desired or expected. We greatly appreciate
your clarification on this issue.

Coder’s Name: __________________________ Coder’s Phone #: _____________________________

Patient Name:    ____________________________________________________________________

Admit Date: _________________        Discharge Date: __________________

MR#: ______________         Acct #: _______________________

The patient must have extensive clinical indicators of aspiration pneumonia present prior to querying. By
extensive clinical indicators, it is meant that the physician has substantially described the clinical condition
about which the coder will inquire but has not made the specific or particular diagnosis.

The medical record reflects the following clinical findings suggestive of aspiration
pneumonia.

    Check Here if                        Clinical indicator                  Location in the medical record which
 indicator is present                                                             reflect the clinical findings
                             Impaired gag reflex
                             Esophageal disorder (obstruction,
                             cancer, stenosis, varices)
                             Dysphagia
                             Positive Swallowing Study
                             Positive Infiltrate on Chest x-ray

Please respond to the following question:

Based on your medical judgement of the clinical indicators outlined above, are you treating this
patient for a known or suspected aspiration pneumonia?

                 Yes – [If yes, please document the specific diagnosis in the space below and/or in the body of the
                 medical record (progress notes, dictated report or as an addendum to a dictated report)].

                 ______________________________________

                 _______________________________                     _________________________
                 PHYSICIAN SIGNATURE                                     DATE

                 No – [If no, please initial in or check the box, and sign and date below. This form will need to be
                 maintained with the medical record].

                 Unable to determine– [If so, please initial in or check the box, and sign and date below. This form will need
                 to be maintained with the medical record.]

                          ____________________________                     ______________________
                          Physician Signature                              Date


                                                                                             Attachment to HIM.COD.012
Query Form C – Sepsis with Positive Blood Cultures

             SEPSIS with POSITIVE BLOOD CULTURES
                    PHYSICIAN QUERY FORM
                          THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                Please return this form by fax to:
Dear Dr. ____________________________:                                   XXX-XXX-XXXX


In responding to this query, please exercise your independent professional judgment. The fact that a
question is asked does not imply that any particular answer is desired or expected. We greatly appreciate
your clarification on this issue.

Coder’s Name: _______________________ Coder’s Phone #: ________________________________

Patient Name: ________________________________________________________________

Admit Date: ___________________             Discharge Date: ____________________

MR#: ___________________                    Acct #: ___________________

The medical record reflects the diagnosis of sepsis in the (medical record location(s)
___________________________________________________ and the blood culture shows (insert
organism)______________________________________________________________.


Please respond to the following question:

Based on the above information, can you identify the known or suspected specific
organism responsible for this patient’s sepsis?

                 Yes – [If yes, please document the specific type of organism that was treated and
                 was responsible for the sepsis in the space below and/or in the medical record
                 (progress notes, dictated report or an addendum to a dictated report).]

                 ______________________________________


                 _______________________________           _________________________
                 PHYSICIAN SIGNATURE                           DATE


                 No- [If no, please initial in or check the box, and sign and date below. This form will
                 need to be maintained with the medical record.]


                 Unable to determine- [If so, please initial in or check the box, and sign and date
                 below. This form will need to be maintained with the medical record.]



                         _______________________________            _________________________
                         PHYSICIAN SIGNATURE                            DATE




                                                                               Attachment to HIM.COD.012
Query Form D – Generalized Sepsis
                                       GENERALIZED SEPSIS
                                      PHYSICIAN QUERY FORM
                                THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                          Please return this form by fax to:
Dear Dr. ____________________________:                                             XXX-XXX-XXXX

In responding to this query, please exercise your independent professional judgment. The fact that a question is
asked does not imply that any particular answer is desired or expected. We greatly appreciate your clarification
on this issue.
Coder’s Name: ____________________________Coder’s Phone #: _____________________________

Patient Name:    ______________________________________________________________________

Admit Date: ______________________                Discharge Date: _________________________

MR#: __________________    Acct #: __________________________

The physician must have documented a localized infection and the patient must have extensive clinical indicators
of a generalized sepsis present prior to querying. By extensive clinical indicators, it is meant that the physician has
substantially described the clinical condition about which the coder will inquire but has not made the specific or
particular diagnosis.

The medical record reflects the following clinical findings suggestive of sepsis.
    Check Here if                        Clinical indicator                     Location in the medical record
 indicator is present                                                          which reflect the clinical findings
                         Fever or hypothermia
                         Tachpnea
                         Tachycardia
                         Oliguria
                         Hypotension
                         Metabolic acidosis (elev lactate level,
                         anion gap or reduced blood pH)
                         Acute onset of confusion associated
                         with disease process/Altered Mental
                         Status
                         Shock
                         Positive Blood Culture - _________
Please respond to the following question:
Based on your medical judgement of the clinical indicators outlined above, are you treating this patient
for a known or suspected generalized sepsis?

                 Yes – [If yes, please document the specific diagnosis {and responsible organism, if applicable) in the space
                 below and/or in the body of the medical record (progress notes, dictated report or as an addendum to a dictated
                 report).]
                 ______________________________________

                 _______________________________                     _________________________
                 PHYSICIAN SIGNATURE                                     DATE

                 No – [If no, please initial in or check the box, and sign and date below. This form will need to be maintained with
                 the medical record].

                 Unable to determine – [If so, please initial in or check the box, and sign and date below. This form will need to be
                 maintained with the medical record].

                          ____________________________                     ______________________
                          Physician Signature                              Date


                                                                                                     Attachment to HIM.COD.012
Query Form E - Urosepsis

                                       UROSEPSIS
                                 PHYSICIAN QUERY FORM
                            THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD
Date: _______________________________
                                                                        Please return this form by fax to:
Dear Dr. ____________________________:                                           XXX-XXX-XXXX

In responding to this query, please exercise your independent professional judgment. The fact that a
question is asked does not imply that any particular answer is desired or expected. We greatly appreciate
your clarification on this issue.

Coder’s Name: ___________________________ Coder’s Phone #: ____________________________

Patient Name:_________________________________________________________________________

Admit Date:____________________ Discharge Date: ______________________

MR#: __________________________                  Acct #:___________________

The physician must have documented urosepsis and the patient must have extensive clinical indicators of
a generalized sepsis present prior to querying. By extensive clinical indicators, it is meant that the
physician has substantially described the clinical condition about which the coder will inquire but has not
made the specific or particular diagnosis.

The medical record reflects the following clinical findings:
    Check Here if                  Clinical indicator                      Location in the medical record which reflect
 indicator is present                                                                   the clinical findings
                         Fever or hypothermia
                         Tachpnea
                         Tachycardia
                         Oliguria
                         Hypotension
                         Metabolic acidosis (elev lactate level,
                         anion gap or reduced blood pH)
                         Acute onset of confusion associated
                         with disease process/Altered Mental
                         Status
                         Shock
                         Positive Blood Culture - _________

Please respond to the following question:
Official Coding Guidelines maintain that in order to ensure accurate coding practices, the physician should
be asked if the diagnosis of urosepsis with clinical indications of sepsis is intended to mean: (1) generalized
sepsis (septicemia) or (2) urine contaminated by bacteria, bacterial by-products, or other toxic material but
without other findings.

When using the terminology of “urosepsis,” do you mean:
        Septicemia/Sepsis or a Localized Urinary Tract Infection – [Please document the specific diagnosis {and
                responsible organism, if applicable} in the space below and/or in the medical record (progress notes,
                dictated report or as an addendum to a dictated report) .]

        _________________________________________________


        _____________________________           ________________
        Physician Signature                      Date


                                                                                         Attachment to HIM.COD.012
Query Form F - General
                                   PHYSICIAN QUERY FORM
                                  THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                  Please return this form by fax to:
Dear Dr. ____________________________:                                     XXX-XXX-XXXX


In responding to this query, please exercise your independent professional judgment. The fact that a question is asked
does not imply that any particular answer is desired or expected. We greatly appreciate your clarification on this issue.

Coder’s Name: ___________________________Coder’s Phone #:_________________________________

Patient Name: _____________________________________________________________________

Admit Date: __________ ___________         Discharge Date: ____________________

MR#: _______________________               Acct #: ___________________

The medical record reflects the following clinical findings (include reference to source document):




Please respond to the following question:




PHYSICIAN RESPONSE:

                Yes – [If yes, please document your response in the space below and/or in the body of the medical record
                (progress notes, dictated report or as an addendum to a dictated report).]
                ____________________________________________________________________________________________

                ____________________________________________________________________________________________

                ____________________________________________________________________________________________

                ____________________________________________________________________________________________

                ____________________________              ______________________
                   Physician Signature                    Date

                No – [If no, please initial in or check the box, and sign and date below. This form will need to be
                maintained with the medical record.]

                Unable to determine – If so, please initial in or check the box, and sign and date below. This form
                will need to be maintained with the medical record.]


                ____________________________              ______________________
                   Physician Signature                    Date



                                                                                                 Attachment to HIM.COD.012
Query Form A – Pneumonia                                For use when the facility’s PRO requires physician
                                                       documentation in the body of the traditional medical record.
                                         PNEUMONIA
                                    PHYSICIAN QUERY FORM
                                  THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                       Please return this form by fax to:
Dear Dr. ____________________________:                                          XXX-XXX-XXXX


In responding to this query, please exercise your independent professional judgment. The fact that a question is asked
does not imply that any particular answer is desired or expected. We greatly appreciate your clarification on this issue.

Coder’s Name: _______________________ Coder’s Phone #: _______________________________

Patient Name: ________________________________________________________________

Admit Date: ________________               Discharge Date: _______________________

MR#:    ___________________          Acct #: ______________________________________


The medical record reflects the diagnosis of pneumonia in the (progress notes, dictated report, history and
physical)__________________________________________________________________________
and the sputum culture shows (specify organism identified in the sputum culture(s) ________________
________________________________________________________________________________.


Please respond to the following questions and take the appropriate action based on your response:

Based on the above information, can you identify the specific organism responsible for this
patient’s pneumonia?

                        Yes – [If yes, then per PRO guidelines please document the specific type of organism that was treated and was
                        responsible for the pneumonia in medical record (progress notes, dictated report or an addendum to a dictated
                        report)].




                        No- [If no, please initial in or check the box, and sign and date below. This form will need to be maintained with
                        the medical record.]



                        Unable to determine – [If so, please initial in or check the box, and sign and date below. This form will need
                        to be maintained with the medical record. ]




                        _______________________________                    _________________________
                        PHYSICIAN SIGNATURE                                    DATE




                                                                                                           Attachment to HIM.COD.012
Query Form B – Aspiration Pneumonia                        For use when the facility’s PRO requires physician
                                                          documentation in the body of the traditional medical record.
                              ASPIRATION PNEUMONIA
                              PHYSICIAN QUERY FORM
                            THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                          Please return this form by fax to:
Dear Dr. ____________________________:                                             XXX-XXX-XXXX


In responding to this query, please exercise your independent professional judgment. The fact that a
question is asked does not imply that any particular answer is desired or expected. We greatly appreciate
your clarification on this issue.

Coder’s Name: ______________________________ Coder’s Phone #: _________________________

Patient Name:    ____________________________________________________________________

Admit Date: ______________________       Discharge Date: ________________

MR#: ______________________________               Acct #: ________________________________

The patient must have extensive clinical indicators of aspiration pneumonia present prior to querying. By
extensive clinical indicators, it is meant that the physician has substantially described the clinical condition
about which the coder will inquire but has not made the specific or particular diagnosis.

The medical record reflects the following clinical findings suggestive of aspiration
pneumonia.

    Check Here if                       Clinical indicator                  Location in the medical record which
 indicator is present                                                            reflect the clinical findings
                             Impaired gag reflex
                             Esophageal disorder (obstruction,
                             cancer, stenosis, varices)
                             Dysphagia
                             Positive Swallowing Study
                             Positive Infiltrate on Chest x-ray

Please respond to the following question:

Based on your medical judgement of the clinical indicators outlined above, are you treating this
patient for a known or suspected aspiration pneumonia?

                 Yes – [If yes, then per PRO guidelines please document the specific diagnosis in the body of the
                 medical record (progress notes, dictated report or as an addendum to a dictated report)].




                 No – [If no, please initial in or check the box, and sign and date below. This form will need to be
                 maintained with the medical record].

                 Unable to determine– [If so, please initial in or check the box, and sign and date below. This form
                 will need to be maintained with the medical record.]

                          ____________________________                    ______________________
                          Physician Signature                             Date



                                                                                            Attachment to HIM.COD.012
Query Form C – Sepsis with Positive             For use when the facility’s PRO requires physician
Blood Cultures                                  documentation in the body of the traditional medical record.
             SEPSIS with POSITIVE BLOOD CULTURES
                    PHYSICIAN QUERY FORM
                          THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                 Please return this form by fax to:
Dear Dr. ____________________________:                                    XXX-XXX-XXXX


In responding to this query, please exercise your independent professional judgment. The fact that a
question is asked does not imply that any particular answer is desired or expected. We greatly appreciate
your clarification on this issue.

Coder’s Name: ___________________________ Coder’s Phone #_____________________________

Patient Name: ________________________________________________________________

Admit Date: ______________________         Discharge Date: _____________

MR#: ________________ ____________ Acct #: _______________________________


The medical record reflects the diagnosis of sepsis in the (medical record location(s)
___________________________________________________ and the blood culture shows (insert
organism)______________________________________________________________.


Please respond to the following question:

Based on the above information, can you identify the known or suspected specific
organism responsible for this patient’s sepsis?

                 Yes – [If yes, then per PRO guidelines please document the specific type of
                 organism that was treated and was responsible for the sepsis in the medical record
                 (progress notes, dictated report or an addendum to a dictated report).]



                 No- [If no, please initial in or check the box, and sign and date below. This form will
                 need to be maintained with the medical record.]


                 Unable to determine- [If so, please initial in or check the box, and sign and date
                 below. This form will need to be maintained with the medical record.]



                         _______________________________             _________________________
                         PHYSICIAN SIGNATURE                             DATE




                                                                                  Attachment to HIM.COD.012
Query Form D – Generalized Sepsis                          For use when the facility’s PRO requires physician
                                                          documentation in the body of the traditional medical record.
                                       GENERALIZED SEPSIS
                                      PHYSICIAN QUERY FORM
                                 THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                          Please return this form by fax to:
Dear Dr. ____________________________:                                             XXX-XXX-XXXX

In responding to this query, please exercise your independent professional judgment. The fact that a question is
asked does not imply that any particular answer is desired or expected. We greatly appreciate your clarification
on this issue.
Coder’s Name: _____________________________Coder’s Phone #: ____________________________

Patient Name:    ______________________________________________________________________

Admit Date:___________________                    Discharge Date: _______________

MR#:______________________________                Acct #: ___________________

The physician must have documented a localized infection and the patient must have extensive clinical indicators
of a generalized sepsis present prior to querying. By extensive clinical indicators, it is meant that the physician has
substantially described the clinical condition about which the coder will inquire but has not made the specific or
particular diagnosis.
The medical record reflects the following clinical findings suggestive of sepsis.
    Check Here if                       Clinical indicator                      Location in the medical record
 indicator is present                                                          which reflect the clinical findings
                             Fever or hypothermia
                             Tachpnea
                             Tachycardia
                             Oliguria
                             Hypotension
                             Metabolic acidosis (elev lactate level,
                             anion gap or reduced blood pH)
                             Acute onset of confusion associated
                             with disease process/Altered Mental
                             Status
                             Shock
                             Positive Blood Culture - __________

Please respond to the following question:
Based on your medical judgement of the clinical indicators outlined above, are you treating this patient
for a known or suspected generalized sepsis?

                 Yes – [If yes, then per PRO guidelines please document the specific diagnosis {and responsible organism, if
                 applicable} in the body of the medical record (progress notes, dictated report or as an addendum to a dictated
                 report).]


                 No – [If no, please initial in or check the box, and sign and date below. This form will need to be maintained with
                 the medical record].


                 Unable to determine – [If so, please initial in or check the box, and sign and date below. This form will need to be
                 maintained with the medical record].

                          ____________________________                     ______________________
                          Physician Signature                              Date

                                                                                                     Attachment to HIM.COD.012
Query Form E – Urosepsis                                   For use when the facility’s PRO requires physician
                                                          documentation in the body of the traditional medical record.
                                            UROSEPSIS
                                      PHYSICIAN QUERY FORM
                                THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD
Date: _______________________________
                                                                         Please return this form by fax to:
Dear Dr. ____________________________:                                            XXX-XXX-XXXX

In responding to this query, please exercise your independent professional judgment. The fact that a question is
asked does not imply that any particular answer is desired or expected. We greatly appreciate your clarification
on this issue.

Coder’s Name: ____________________________Coder’s Phone :_______________________________

Patient Name:_________________________________________________________________________

Admit Date:________________________               Discharge Date: ________________________

MR#: _________________                            Acct #:___________________

The physician must have documented urosepsis and the patient must have extensive clinical indicators of a
generalized sepsis present prior to querying. By extensive clinical indicators, it is meant that the physician has
substantially described the clinical condition about which the coder will inquire but has not made the specific or
particular diagnosis.

The medical record reflects the following clinical findings:
    Check Here if                  Clinical indicator                      Location in the medical record which reflect
 indicator is present                                                                   the clinical findings
                         Fever or hypothermia
                         Tachpnea
                         Tachycardia
                         Oliguria
                         Hypotension
                         Metabolic acidosis (elev lactate level,
                         anion gap or reduced blood pH)
                         Acute onset of confusion associated
                         with disease process/Altered Mental
                         Status
                         Shock
                         Positive Blood Culture - ________

Please respond to the following question:

Official Coding Guidelines maintain that in order to ensure accurate coding practices, the physician should be
asked if the diagnosis of urosepsis with clinical indications of sepsis is intended to mean: (1) generalized sepsis
(septicemia) or (2) urine contaminated by bacteria, bacterial by-products, or other toxic material but without other
findings.

When using the terminology of “urosepsis,” do you mean:
        _________Septicemia/Sepsis – [If so, please document the specific diagnosis in the medical record (progress notes,
                dictated report or as an addendum to a dictated report) per PRO guidelines.]

        ________ Localized UTI – [If so, please sign and date below. ]

                           ____________________________                  ______________________
                           Physician Signature                           Date


                                                                                                 Attachment to HIM.COD.012
Query Form F - General                               For use when the facility’s PRO requires physician
                                                    documentation in the body of the traditional medical record.

                                   PHYSICIAN QUERY FORM
                                  THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD


Date: _______________________________
                                                                  Please return this form by fax to:
Dear Dr. ____________________________:                                     XXX-XXX-XXXX


In responding to this query, please exercise your independent professional judgment. The fact that a question is asked
does not imply that any particular answer is desired or expected. We greatly appreciate your clarification on this issue.

Coder’s Name: __________________________Coder’s Phone #:__________________________________

Patient Name: _____________________________________________________________________

Admit Date:___________________             Discharge Date: ____________________

MR#: _______________                       Acct #:___________________

The medical record reflects the following clinical findings (include reference to source document):




Please respond to the following question:




PHYSICIAN RESPONSE:

                Yes – [If yes, then per PRO guidelines please document your response in the body of the medical
                record (progress notes, dictated report or as an addendum to a dictated report).]



                No – [If no, please initial in or check the box, and sign and date below. This form will need to be
                maintained with the medical record.]

                Unable to determine – If so, please initial in or check the box, and sign and date below. This form
                will need to be maintained with the medical record.]


                ____________________________              ______________________
                   Physician Signature                    Date




                                                                                                    Attachment to HIM.COD.012

				
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Description: Query Writing in Clinical Data Management document sample