The Coder's Guide to Physician Queries

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The Coder's Guide to Physician Queries

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The Coder’s Guide to Physician Queries

Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIPContributor: Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE

With frequent ICD-10-CM/PCS code updates, policy changes, and advances in electronic query systems, coders are constantly being challenged to redefine where and how they generate queries. Without an efficient and effective query process, facilities risk denials and audits that can cost them significant time and money.

The Coder’s Guide to Physician Queries provides easy-to-follow strategies for coding departments to improve their query processes and train their coders on developing and executing physician queries. Using the tools in this guide, new and established coders can revise their practices and train staff to meet the challenges of integrating ICD-10-CM/PCS codes into queries, government payer initiatives, auditor denials, and electronic advances.

With sample queries, policies, and procedures for both inpatient and outpatient perspectives, The Coder’s Guide to Physician Queries is a valuable addition to any coding library.

In addition to sample queries and templates, this book provides:

  • A comprehensive review of queries, including best practices for coders in an evolving regulatory environment
  • An overview of healthcare reimbursement initiatives pertinent to coder query practices in the current regulatory environment
  • A start-to-finish guide on the entire query process, including:
    • How to develop a facility/systemwide policy and procedure
    • How to review the record
    • How to understand physician judgment and leading queries
    • An overview of query types
    • Analysis of AHIMA guidelines for physician queries and compliance concerns essential for coding integrity and success


About the Authors:

Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, serves as a regulatory specialist for HCPro, a division of Simplify Compliance, teaching the Certified Coder Boot Camp® programs. She is an instructor with extensive knowledge of inpatient coding guidelines as well as E/M and auditing guidelines. She has many years of experience in the healthcare industry, including coding, auditing, training, and compliance expertise.

Prior to joining HCPro, Commeree was a coding auditor/medical assistance program specialist with the Washington State Health Care Authority (HCA) Clinical Review Unit, working within the state’s Medicaid program. She oversaw inpatient coding audits for the majority of Washington’s hospitals, which included audits for inpatient claims, DRG assignments, and coverage and payment policies. She also served as a coding consultant to other HCA departments by assisting providers, policymakers, and data analysts to identify aberrant coding patterns and potential fraud, waste, and abuse. Before working for Washington HCA, she served as a coding specialist and trauma registrar with Trauma Trust, an organization that serves two major healthcare systems in the Tacoma area by providing Level II trauma and acute care surgical services.

Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, is chief operating officer of First Class Solutions, Inc., of St. Louis. Her firm provides interim management services, operational guidance for HIM and revenue cycle departments, physician office compliance services, and coding compliance reviews. She is the principal author of HCPro’s The Practical Guide to Release of Information: ROI in a HITECH World.

Published: November 2017

Page count:126
Dimensions: 8.5” X 11”
ISBN: 978-1-68308-677-2

Table of Contents

  • Healthcare Reimbursement Initiatives (updated with new guidance)
    • Healthcare reimbursement: CMS and the IPPS
    • Value-based purchasing
    • Patient Safety Indicators
    • Outpatient payments
  • Regulatory Environment (updated with any new guidance)
    • False Claims Act
    • Enforcement efforts: OIG, CERT, PEPPER, MAC, MIC
    • Recovery Auditors and the audit process
  • Coding Advancements
    • Specificity requirements under ICD-10
    • Incorporating coding regulations into query efforts
  • Query Guidance Progression
    • CMS
    • AHIMA publications
    • AHIMA/AAPC Code of Ethics
    • Input from CDI professionals
  • The Query Process
    • Outpatient query process (R.D Book)
    • Developing facility/systemwide policies and procedures
    • How to review the record
      • Principal and secondary diagnoses
      • Unspecified diagnoses
      • Diagnosis sequencing
      • Clinical indicators
    • Physician judgment and leading queries
    • Query types
      • Open ended
      • Multiple choice
      • Yes/no queries
      • Queries as a permanent part of the medical record
      • Outpatient CPT queries
  • Electronic Health Records and the Advancement of eQueries (rework with R.D book material)
    • The problem with the problem list
    • Establishing effective eQuery etiquette
    • Balancing eQuery efforts with on-site physician education and engagement
  • Query Assessments, Program Auditing, and Education Opportunities (rework with R.D book material)
    • Coding/CDI collaboration efforts
    • Retrospective and prospective audits for effectiveness