Leading queries
The ever popular subject---
I have a clear opinion on this subject and feel that the 2013 AHIMA practice brief clarified a "leading"query as one that is not clinically substantiated by the record.
Working with a new coding group they believe that my query is leading. They say they would never introduce a diagnosis stated in the record. I shared the brief and highlighted the section that a new CLINICALLY SUPPORTED diagnosis was not leading if given choices and not directing the provider to one answer.
I gave the clinical indicators - most significant room air sat of 81% with no noted respiratory condition. Lasix (no reported cardiac hx either), repeat xray and Oxygen.SOB,"increasing o2 demand"
multiple choice answer:
acute respiratory failure
atelectais only
no evidence of respiratory failure
Other
[ I don't use unable to determine- because I feel that can be written easily in other and avoids defiance - i know not everyone would agree but the main point is that they have choices which i feel they have}
SO MY QUESTION does anyone have a process or solution that they have used/experienced to help come to an understanding of this being acceptable?
I was told the coder would not code the agreement by the physician. They want me to only be able to query concurrently so my query is not in the record. I feel my query has to be compliant as if it is in the record, regardless of an institutional decision.
I think if coding questions the clinical indicators that is one issue and we need to establish an escalation policy and possibly have physician input.
Second issue is whether the format is leading and if agreed that new diagnosis introduced in MC format it should be coded.
Love to hear anyone who has successfully worked with their coding department toward this solution.
Thanks and feel free to email me anything as well.
Ann
annnd2009@gmail.com
I have a clear opinion on this subject and feel that the 2013 AHIMA practice brief clarified a "leading"query as one that is not clinically substantiated by the record.
Working with a new coding group they believe that my query is leading. They say they would never introduce a diagnosis stated in the record. I shared the brief and highlighted the section that a new CLINICALLY SUPPORTED diagnosis was not leading if given choices and not directing the provider to one answer.
I gave the clinical indicators - most significant room air sat of 81% with no noted respiratory condition. Lasix (no reported cardiac hx either), repeat xray and Oxygen.SOB,"increasing o2 demand"
multiple choice answer:
acute respiratory failure
atelectais only
no evidence of respiratory failure
Other
[ I don't use unable to determine- because I feel that can be written easily in other and avoids defiance - i know not everyone would agree but the main point is that they have choices which i feel they have}
SO MY QUESTION does anyone have a process or solution that they have used/experienced to help come to an understanding of this being acceptable?
I was told the coder would not code the agreement by the physician. They want me to only be able to query concurrently so my query is not in the record. I feel my query has to be compliant as if it is in the record, regardless of an institutional decision.
I think if coding questions the clinical indicators that is one issue and we need to establish an escalation policy and possibly have physician input.
Second issue is whether the format is leading and if agreed that new diagnosis introduced in MC format it should be coded.
Love to hear anyone who has successfully worked with their coding department toward this solution.
Thanks and feel free to email me anything as well.
Ann
annnd2009@gmail.com