Coding, Classification and Reimbursement

physician queries

  • 1.  physician queries

    Posted 30 days ago

    Question, our facility is asking us to query the supervising physician first before we query the PA-C, CRNP, NP, etc. who is the one who actually saw the patient to comply with proper medical record documentation. But, the Dr. will just say to ask the PA. This takes especially in an urgent care setting (that I code) where the seeing physician may only be one a week or every couple of weeks. is there a national or state guideline about this? Or is it each individual facility's call or policy regarding what they can and cannot take. And would you just query on missing diagnosis, questioning procedures only? Or if they are missing the note completely or missing the PE, HPI, or ROS too??

    Brandy Giovanni
    Coding Specialist

  • 2.  RE: physician queries

    Posted 29 days ago
    Hello Brandy,

    I'm not a CDI expert, but I'll tell you what I do know based on my experience. If the clinical documentation requires a query, the query goes to whomever actually wrote the note. The only exception would be in an instance when a PA, NP, or physician consultant documents something which contradicts documentation written by the attending, in which case the query goes to the attending for clarification because they are the final word on the patient's condition. The top reasons to query would be legibility (if the notes are handwritten), consistency, lack of clarity or specificity, 'missing diagnoses' in the sense of clinical indicators or diagnostic results without an associated diagnosis.

    When a note or required component of a note is missing entirely, that is a physician deficiency which is a totally separate process from querying. I've never worked in urgent care, but I know that hospitals usually have an established process for tracking and follow-up of deficiencies. In these situations it is especially important to have a solid working relationship with your medical director, as they act as the primary go-between for HIM and the providers.

    Jacqueline Mccauley
    Him Director

  • 3.  RE: physician queries

    Posted 28 days ago
    Hi Brandy!

    Our facility does query the NP/PA for documentation clarification.  It must however, be co-signed by the supervising MD.

    Thank you!

    Michellene Fryson
    Audit and Compliance Manager

  • 4.  RE: physician queries

    Posted 16 days ago

    Our facility has a "hospitalist/internal medicine teaching program.  Attendings in this program will not answer queries.  They must be submitted to the resident or PA on the case.

    Lawrence Barr
    Coder 3

  • 5.  RE: physician queries

    Posted 15 days ago
    With residents I would be cautious.   Residents information is reportable if not contradicted by the attending.   A query process that bypasses the attending does not provide a means for the attending to indicate if they have a differing opinion.   I'm not sure I'd agree bypassing the attending falls into best practices in a teaching physician situation.

    In regards to PA's, as long as you are in a situation where PA's documention is reportable, and the physician has directed you to the PA for the response, I wouldn't see a problem with that.   That's not bypassing the MD in the same way

  • 6.  RE: physician queries

    Posted 15 days ago
    ​Hi all ~
    I concur with Jonathan's comments and would also recommend reviewing your facility's medical staff bylaws/rules & regulations as it relates to medical records and provider documentation within the patient record.  I have found from time to time that can help solidify the need for additional queries since the expectations of all providers is usually documented in these policies.

    Good luck!

    Lynn A. Wall, MBA, RHIT, CCS
    Interim Coding Supervisor
    Maricopa Integrated Health System