MEDAILLE MEDICAL CENTER

HIA 406E
Team One

PHYSICIAN DOCUMENTATION QUERY POLICY & PROCEDURE

SCOPE
This policy applies to all physician documentation queries for services provided at Medaille
Medical Center. All personnel responsible for outpatient coding, including clinical coders,
supervisors and clinical documentation improvement specialists shall abide by this policy.
PURPOSE
Use of the physician query process will elicit communication amongst coding staff and
physicians so to clarify unclear documentation in the medical record. This practice will improve
the quality of documentation and coding in order to accomplish the complete capture of clinical
data.
POLICY
As per Medaille Medical Center, a physician query should be initiated when documentation in
the medical record is deemed to lack clarity, consistency, completeness, precision or legibility.
Queries may be concurrent, retrospective, or post-bill.
A physician query may be necessary in the following situations:

When clinical indicators of a diagnosis are present but there is no documentation of the
condition in the medical record
When there is clinical evidence for a higher degree of specificity or severity
When there is a cause-and-effect relationship between two conditions or an organism
When it is found that only the treatment is documented (no diagnosis is documented)

A physician query should not be initiated to question a physicians judgment, or to question

insignificant reportable conditions or procedures.
The query process can be initiated by coding staff and the documentation improvement team.
DEFINITIONS
Query: A communication between a coder and physician to clarify ambiguous, incomplete or
conflicting documentation in the medical record.
Concurrent Query: A query that is initiated during the course of the patient encounter during the
time that the documentation is actually done.
Retrospective Query: A query that is initiated after discharge, but before billing.
Post Bill Query: A query that is initiated after the claim is submitted usually in response to an
audit. Post bill queries will be re-billed following normal business guidelines using payerspecific rebilling timeframes.

MEDAILLE MEDICAL CENTER

HIA 406E
Team One

PROCEDURE
1. Queries should be initiated by coding staff when documentation:
a) Is not complete
b) Is not legible
c) Is not clear
d) Is not precise
e) Lacks consistency
f) Lacks evidence to back up a diagnosis
g) A cause-and-effect relationship is not indicated between two
conditions that may be integral
h) There is documentation of treatment for an undocumented
condition
i) There is clinical evidence that a condition has a higher degree of
specificity or severity
2. Coders should utilize all available resources before deciding a query is necessary. References
include but are not limited to:
a) AHA Coding Clinic for ICD-9-CM
b) AMA CPT Assistant
c) Faye Browns ICD-9-CM Coding Handbook
d) ICD-9-CM Official Coding Guidelines
3. Employees involved in the query process must adhere to ethical standards of coding and all
internal policies that pertain to documentation, coding, and querying.
4. Concurrent queries may be communicated either verbally or through use of a physician query
form. Retrospective queries should be completed utilizing the physician query form.
5. Queries should be directed toward the attending physician. Inconsistencies in ancillary
documentation are still reported to the attending physician.
6. Physicians should respond and complete these queries within three weeks of their receipt.
7. Upon receipt, queries will be reviewed and added to the patient's permanent medical record.
Responses to queries may also be documented in the patients progress note or discharge
summary. Addendums to the progress note or discharge summary must be appropriately dated
and authenticated.
8. If a physician does not complete initiated queries before the time period of three weeks, follow
up phone calls should be completed on a weekly basis. If after another period of three weeks the

MEDAILLE MEDICAL CENTER

HIA 406E
Team One

attending cannot be reached, disciplinary action should be taken by the department head.
9. In order to ensure that queries are completed as per this policy and procedure, queries will be
retrospectively to determine the necessity of the query, whether the query was appropriate and
non-leading, and that new information from the health record was not introduced.
10. Please refer to the Physician Documentation Auditing and Monitoring Program policies and
procedures for specific information regarding this process.
11. Inappropriate queries will be tracked and trended. Coding and documentation improvement
staff will be educated and trained at weekly staff meetings or sooner if deemed necessary.
References:
Schraffenberger, L. A., & Kuehn, L. (2011). Effective management of coding services:
The clinical coding managers handbook (4th ed). Chicago, IL: AHIMA Publications.
Von Kirchoff, S. (2009). Coding and reimbursement for hospital outpatient services.
(2nd ed.). Chicago, IL: AHIMA Publications.
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDoc
Name=bok1_050018
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_040394.hcsp?dDoc
Name=bok1_040394