Question

Learning Plan 09 LPO9.1 Assignment: Physician Query 3d. Develop a physician query when documentation is insufficient to support diagnoses and procedures. Directions: The coder should query the physician when documentation in the patient's record is not sufficient to support the diagnosis in the medical record. The physician query form is a method of communication between the coder and the physician to address documentation that is not sufficient to suppořt the diagnosis. Case Scenario: Patient: Sally James DOB: 10-14-1960 MR #123-34-78 Admitted: 01-03-X)X Physician: Ervin Mass The impression on the pathology report, ovarian cancer is documented; however, only ovarian mass is documented in the final discharge statement by the provider. Develop a physician query form that addresses incomplete or insufficient documentation in the case scenario listed above. The query form must include the following: 1. Patient Identification Information 2. Date of Service 3. Coders Name& Contact Information 4. Query Date 5. Name of Physiciarn 6. Statement of the issue (as it relates to incomplete, vague or insufficient documentation) s recommended that queries be written with precise language, identifying clinical indications from the health record and asking the provider to make a clinical interpretation of these facts based on his or her professional judgment of the case. (AHIMA)

Answer 1

Patient Name: SALLY JAMES

Date of Birth:10. 14.1960

Dates of Stay: 01.03.XX

Medical Record Number: 123 - 34 - 78

Dear Dr. Ervin Mass'

In order to ensure that the reported codes best reflect your patient’s condition, further clarification is required. Please consider the clinical presentation, workup and treatment for this patient and exercise your professional judgement when responding. If you have any questions regarding this query, please contact:

Clinical indication for query is, According to the impression on the pathology report, ovarian cancer is mentioned and ovarian mass is documented in final report. I would like to get the clinical findings, prognosis and your professional judgement to continue diagnosis and treatment.

Thanks&Regards

coder identification is not included in the question.