Question

Physician Query Policy You have suspected that there are problems in the physician query process for a while now, and you have planned to review the policy and query form to look for any compliance issues. You would rather find the problems yourself before the Old finds them. Your task today is to evaluate the physician query process at your facility. Review Figures 5-1 and 5-2 1. Evaluate Figure 5.1 on all aspects including the following: • Good policy and procedure format • Grammar • Process 2. Evaluate Figure 5-2 on all aspects, including the following: . Standards for completion of a proper physician query • Screen design HONOLULU GENERAL HOSPITAL Policy Title: Physician Queries Policy: Physician Queries are used as the sole method of communication between coders and physicians It should be used when there are problems with incomplete documentation, conflicting diagnoses, recommendations for improvement in medical practices, incomplete histories and physicals, incomplete discharge summaries, improving reimbursement, and other documentation issues Procedure: Person Responsible Coder 1. Review health record to determine principal diagnoses. Secondary diagnoses, principal procedure, and other procedures 2. Complete physician query form in electronic health record 3. When query is completed by physician, review physician feedback and make the necessary adjustments to the code assignment Effective date: May 1, 2017 Coder Coder PGORE-1 Policy and Procedure for Physician Queries HONOLULU GENERAL HOSPITAL Physician Query Patient Name: Upon review of the health record documentation for the purpose of coding the following issues were identified Please address the above questions. If you have any questions, please contact: Coder Phone:U L Date: Response: Physician Signature: Date FIGURE 2 Physician Query Screen

Answer 1

1. Upon evaluation of figure 5-1, it was found that the policy and procedure format complies with the requirements of a proper format. the sentences are really concise and precise. This is the expected format, so this can be considered as a good one. The grammar is good and is in the expected level of expertise. The process is of superior quality and is compliant with the requirements.

2. Upon evaluation of figure 5-2, it was found that the standards for completion of a physician query are up to the expected level. The screen design is excellent with only the minimum number of fields, but all the required fields are present in the appropriate order. This query is compliant and nonleading with low-level expression. This is a clarifying documentation meant to improve the completeness and specificity of the data used to assign codes in the patient's health record.