Question

Clinical Documentation Improvement/Physician Query

Subdomain V. D. (2014)

• Choose an example of unclear documentation regarding an inpatient diagnosis in a patient record.
• Develop a physician query to resolve data and ICD-10-CM coding discrepancies

Answer 1

Inpatient diagnosis is a challenging task for the coder. The coder should review the claims submitted for inpatient admissions for certain components like Present of admission indicator assigned to the principal,secondary and external cause of injury code. Issues with unclear documents , conflicting statement, are rectified by initiating the physical query.

The coder checks the inpatient documentation for Y-Yes , N-No, U-Unknwn ,W - Clinically undetermined, I -Unreported. This helps the coder to identify unclear documentation

Example: A patient admitted in ED with the complaints of chest pain. The principal diagnosis is to rule out myocardial infarction. But the patients cardiac markers and Electrocardiogram reports shows negative for MI. But still provider suspects MI. In this scenario coder can code for the signs and symptoms of chest pain,shortness of breath with principal diagnosis. Since the provider statement is not supported by the laboratory studies the coder can initiate physician query.

Query is a process initiated by the coder in order to get clarification on medical record.

Coder must understand the process of physician query like presenting only facts to which clarification is needed. The query must be clear and concise. Provide clinical indicators related to the statement. The written queries should be clear and consists of open ended , multiple choice questions. Must communicate to produce supportive documentation of present medical diagnosis.