Exercise 25 Physician Query: MPI: EDCase013 (Buster Brown) Instructions: Access the Edco Solcom application. : In this exercise, you will review the record, identify diagnoses, physician orders and corresponding treatment; analyze the record for legibility and complete documentation; determine if more information from physician is required for complete coding, and if yes, develop a compliant query. Writing a Compliant Query A proper query process ensures providers add appropriate documentation to the health record in support of accurate code assignment. Personnel performing the query function should maintain a compliant query process. Although verbal queries may be prevalent in the physician practice setting due to the close working relationship, it is important to follow guidance requiring their recording. When writing a query in the physician practice setting, the CDI professional must adhere to the following guidelines: • Do not lead the provider to a certain diagnosis • Include appropriate clinical indicators to support the query • Format the query as open-ended (preferred), multiple choice, or “yes/no” (or “rule in/rule out”) Refer to AHIMA’s January 2016 Practice Brief “Guidelines for Achieving a Compliant Query Practice (2016 Update),” available online in AHIMA’s HIM Body of Knowledge at bok.ahima.org, for additional details on writing compliant queries, including query examples.
References:
AHIMA Inpatient Query Toolkit
Barnette, Erin; Endicott, Melanie; Ericson, Cheryl E; Wieczorek, Michelle M. "Evolving Roles in Clinical Documentation Improvement: Physician Practice Opportunities" Journal of AHIMA 88, no.5 (May 2017): 54-58. Exercise #: 25 Patient Name: MPI: Patient Type: List the discharge diagnoses from the record and identify documents from the record that support the diagnosis: Diagnosis: Supporting Documentation:
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