Querying second time for same diagnosis?
Queried a physician on Friday regarding dsypnea and O2 supplementatio, low P/F ratio. He agreed to acute hypoxic resp flr, but did not carry doc forward in PN on either Saturday or Sunday (per our policy the diagnosis cannot be coded based solely on the Q response, it must appear in the PN and/or D/C Summary). On Monday a new physician is attending. She is not documenting resp flr. Can I send a yes/no query to her asking if she agrees with first MDs answer?
Thank you,
Amy, RN, CCDS
Comments
Hi Amy,
In my practice, I don’t usually use yes/ no querying unless it is about POA status or establishing cause and effect . I believe ACDIS has a good Position Paper regarding AHIMA’s Guidelines on Compliant queries. https://acdis.org/system/files/resources/CR-1434%20ACDIS%20AHIMA%20query%20practice%20position_paper.pdf Since the Dx dropped I may resend the same query again to show compelling clinical indicators, Risk Factors and Treatments. Or If the dx is clinically valid, another option is to send a Rule in or Rule out or Other Explanation multiple choice options with an initial statement about the previously documented diagnosis.
“The documentation of ** is noted in the med record. For consistency in documentation, please continue to document ** if clinically appropriate”. ** is: r/i, r/o or Other explanation.
Hope this helps,
Nina L., MSN,RN,CCDS
mmleal@premierhealth.com