Master Physician Queries - HCPro Blogs

Master Physician Queries 

Clarify coding with compliant questions 

White paper 

Ask the right query, get the right 

reimbursement 

It sounds simple, but physician queries are often anything but 

Well-crafted queries can enhance patient care by improving documentation 

in the medical record. They can also educate physicians on documentation 

requirements. 

Shannon McCall, RHIA, CCS, 

CCS-P, CPC-I, Director of 

Coding and Health Information 

Management, HCPro, Inc. 

FEATURES 

■■ Know when it is necessary 

to query 1 

■■ Understand how to query 

appropriately 3 

■■ Document queries in a 

compliant fashion 3 

■■ Monitor and audit 

physician queries 4 

■■ Manage queries for 

increased specificity 4 

■■ Sample physician query 

form 6 

In addition, coding professionals need to be able to ask physicians for more 

information or clarification to improve the specificity and completeness of 

the codes they assign to receive the right reimbursement. In an age in which 

Medicare recovery audit contractors are looking for claims to deny, the ability 

to ask compliant questions is critical. 

Know when it is necessary to query 

Healthcare providers should provide legible, complete, clear, consistent, 

precise, and reliable documentation on patients they treat, according to the 

October 2, 2008, American Health Information Management Association 

(AHIMA) practice brief, “Managing an Effective Query Process.” This 

includes thorough documentation of history, present illness, and course of 

treatment, as well as the outcomes of all tests, procedures, and treatments. 

Providers should also include documentation to support level of severity, 

anatomical sites, and etiologies of symptoms, as necessary. 

But sometimes, the necessary documentation is not recorded, and coding 

professionals must query physicians for answers. 

According to AHIMA, the following are reasons to query a physician: 

■■ To clarify an illegible entry in the medical record 

■■ To complete an entry (e.g., when a physician neglects to identify 

the significance of an abnormal diagnostic study) 

■■ For clarity (e.g., when a physician lists symptoms without a cause) 

■■ For consistency (e.g., when conflicting documentation by two 

providers is present) 

■■ For precision (e.g., when a coder believes he or she should assign 

a more specific diagnosis than the documentation allows) 

There are times when it is inappropriate for coding professionals to query physicians. 

For example, coders should not use queries to question a provider’s 

physician queries november 2008

2 Physician queries December 2008 

clinical judgment, according to AHIMA. Nor should a coder query the physician 

if a matter is insignificant; coding professionals should query physicians 

only on significant reportable conditions or procedures. 

Although coders often query for financial reasons (i.e., to ensure accurate 

reimbursement), this is not the only reason to do so. Coders should perform 

queries regardless of the financial effect. Most importantly, coding professionals 

should query physicians to improve documentation in a medical 

record, when necessary, for continuity of care. 

According to the AHIMA practice brief, it is appropriate to perform a query 

when: 

■■ The physician includes clinical indicators of a diagnosis but doesn’t 

document the condition 

■■ There is clinical evidence for a higher degree of specificity or 

severity 

■■ There is an undocumented cause-and-effect relationship between 

two conditions 

■■ The physician neglects to determine an underlying cause of 

symptoms 

■■ The physician documents treatment, but not a diagnosis 

Coders should perform queries only when there is conflicting, incomplete, 

or ambiguous documentation in the medical record, according to AHIMA. 

This includes present-on-admission (POA) assignment. Coding professionals 

should query the physician when the POA indicator is unclear. 

It is important for coding 

professionals to thoroughly 

examine all documentation 

in a medical record before 

initiating a query. 

It is important for coding professionals to thoroughly examine all documentation 

in a medical record before initiating a query. Coders should examine 

a patient’s entire clinical picture through any available information in the 

medication record, physician orders, nursing records, or any other ancillary 

department notes. The gathered information may help support the need for a 

query or it may help a coder recognize that a query is unnecessary. Avoiding 

unnecessary queries is also an easy way to prevent irritating physicians. 

Coders may query physicians at one of three points: 

■ ■ Concurrent. Coders may perform concurrent queries during the 

time that the patient is on-site at a facility. This is the timeliest 

way to query and typically results in a highly accurate and reliable 

response from the physician. 

■ ■ Retrospective. Coders may choose to query a physician after the 

patient is discharged, but before the bill is submitted. This method 

is effective when additional information (e.g., lab results or ancillary 

services) is added to the patient record after discharge. 

■ ■ Post bill. Coding professionals may choose to query physicians 

after the claim is submitted and paid. This is usually done for reasons 

related to auditing and internal monitoring. 

© 2008 by HCPro, Inc. Any reproduction is strictly prohibited. For more information, call 877/233-8734 or visit www.revenuecycleinstitute.com.

December 2008 physician queries 3 

Understand how to query appropriately 

Coders should direct their queries to the healthcare provider who originated 

the documentation in question. This may include an attending or consulting 

physician or a surgeon. Coders should generally consult the attending physician 

to clarify abnormal lab results. 

A physician query should state the following information: 

■■ Patient name 

■■ Admission date and/or date of service 

■■ Health record number 

■■ Account number 

■■ Date the coding professional initiated the query 

■■ Name and contact information of the coding professional who 

submit the query 

■■ Relevant facts from the medical record, including dates when 

appropriate 

■■ The need for clarification 

■■ Open-ended questions that allow the physician to document a 

specific diagnosis 

In many cases, facilities have approved forms that coders can use to help 

ensure that coding professionals document queries correctly. (See p. 6 for 

sample form “ABC Medical Center Physician Query.”) Forms may contain 

multiple-choice questions provided that coders list all clinically possible 

choices, along with a field indicating “other,” in which the physician can 

enter free text, when necessary. With the exception of queries regarding 

POA status indicators, queries should not contain yes-or-no questions. 

Queries should not lead the 

physician to an answer in 

any way, appear to direct 

the physician toward a 

specific response, or show 

the financial effects of the 

query. 

In addition, queries should not lead the physician to an answer in any way, 

appear to direct the physician toward a specific response, or show the financial 

effects of the query. Leading queries could incite allegations of upcoding 

against a provider. According to the AHIMA practice brief, a query shouldn’t 

“sound presumptive, directing, prodding, probing, or as though the provider 

is being led to make an assumption.” 

Providers should verify that their forms are compliant with the newly 

released practice brief. For example, form titles (e.g., “Sepsis Query Form”) 

may lead physicians to a certain answer. Consider nonleading alternatives 

instead (e.g., “Pulmonary Query Form”). 

Document queries in a compliant fashion 

Coders may submit queries in several ways, including via fax, secure e-mail, 

or an instant messaging system, according to AHIMA. Coders should not 

write queries on sticky notes, scrap paper, or anything easily lost, removed, or 

discarded. This is important because queries must be documented within the 

medical record. The process documenting queries differs between facilities. 

However, one common method includes having the physician add a late 



entry or addendum to the medical record by way of a progress note, addition 

to a discharge summary, or history and physical. The physician must date 

and authenticate the documentation. Alternatively, the query form may be 

filed in the permanent medical record in its original format. Compliance staff 

members or legal counsel should be involved in this decision to ensure that 

the facility properly complies with all applicable state and quality improvement 

organization guidelines. 

Providers should address 

the use of verbal queries 

in their policies and 

procedures to avoid the 

risk of noncompliance, 

according to AHIMA. 

Providers should address the use of verbal queries in their policies and procedures 

to avoid the risk of noncompliance, according to AHIMA. Coding 

professionals should remember that the goal of a verbal query is a documented 

response, not necessarily a verbal one. 

Monitor and audit physician queries 

Facilities should monitor queries to look for unnecessary, leading, or otherwise 

noncompliant queries. Internal monitoring can also track the overuse 

of queries. Track trends and provide additional education as necessary. 

Monitoring queries can also help facilities measure documentation improvement 

by providers and determine whether education in specific areas of 

documentation requirements would be helpful. 

It is important to note that facilities should regularly perform audits of 

queries to be most effective. Facilities should monitor the query process by 

reviewing a representative sample of all queries performed and a sampling 

of a specific coder’s queries. 

According to AHIMA, an effective program should audit the following: 

■ ■ Percentage of positive and negative query responses. A high 

percentage of negative responses may mean coders are querying 

unnecessarily, whereas a high percentage of positive responses 

may indicate physicians may need education to rectify a pattern of 

incomplete documentation. 

■ ■ Format of queries. Education for coding professionals may be necessary 

if trends showing inappropriate query formats are present. 

■ ■ Individual providers. This form of monitoring will indicate whether 

specific healthcare providers would benefit from additional documentation 

improvement education, resulting in a decreased number 

of queries for the provider. 

■ ■ High-risk diagnoses. Auditing problematic diagnoses may show 

whether additional education on specific diagnoses would be helpful. 

Manage queries for increased specificity 

CMS’ emphasis on coding specificity means that healthcare providers need 

to provide documentation to accurately reflect patient severity. The implementation 

of Medicare Severity (MS) DRGs, the use of complications and 

comorbidities (CC) and major CCs, the requirement to report POA indicators, 

and potential payment adjustments for hospital-acquired conditions 



are all evidence of CMS’ increasing requirement for coding professionals to 

report the most specific codes possible. 

Providing physicians with continuing education on the necessity of complete 

documentation is one way to reduce the number of queries. But a certain 

number of queries will probably continue to be necessary despite the most 

thorough educational efforts. And that means dealing with physicians. 

Careful, thoughtful queries 

may help reduce the 

irritation physicians may 

feel when responding. 

Careful, thoughtful queries may help reduce the irritation physicians may 

feel when responding. To this end, the AHIMA practice brief recommends 

that those coding professionals who query physicians should be able to: 

■■ Apply knowledge of regulations (e.g., reimbursement and documentation 

requirements) 

■■ Read and analyze all information in a medical record 

■■ Communicate with providers and other clinical staff members 

■■ Be skilled in medical terminology and coding 

Although querying inevitably slows down the billing and reimbursement 

process, assigning specific codes may help facilities’ bottom lines. In many 

cases, more specific documentation allows coders to report higher-paying 

MS-DRGs. 

Even more importantly, thorough documentation is crucial to patient care. 

And remember, in an era of pay-for-performance, quality care is important 

for more than just patients. n 

Editor’s note: To view the AHIMA practice brief, “Managing an Effective Query 

Process,” visit www.ahima.org/infocenter/practice_tools.asp and click on Coding 

and Reimbursement. If you have questions about physician queries, send an e-mail to 

McCall at revenuecyclemanagement@hcpro.com. 

Resources 

American Health Information Management Association, “Managing an 

Effective Query Process.” October 2, 2008. 



ABC MEDICAL CENTER PHYSICIAN QUERY 

The documentation in this patient’s medical record requires additional clarification to accurately capture the 

patient’s diagnoses, treatment, acuity and/or severity of illness per CMS guidelines. 

Date of query:_ _________________ Attention: Dr._________________________________________________ 

Patient name: ___________________________________ Patient admission date: ________________________ 

Patient health record number: _ ____________________ ❑ M / ❑ F Age: _______________________ 

Patient account number: __________________________ 

Question:_____________________________________________________________________________________ 

_____________________________________________________________________________________________ 

Please evaluate your patient regarding the following criteria. When appropriate, document accordingly in your 

next progress note or indicate an alternative diagnosis. Please consider the clinical presentation, workup, and 

treatment for this patient and exercise your professional judgment when responding. 

❑ BACTEREMIA. Per ICD-9 guidelines, bacteremia indicates that the patient has the presence of bacteria in the 

blood, but does not infer the bacteria is pathological or has resulted in any systemic illness needing treatment. 

❑ SIRS. Any two of the following with an infectious or noninfectious etiology: 

Temp = < 96.8°F or > 100.4°F 

RR = > 20/min or PaCO2 < 32 mmHG 

HR = > 90 bpm 

WBC = < 4000 or > 12,000; or > 10% bands 

❑ SEPSIS. SIRS with an identified source or suspected source of infection. 

❑ SEVERE SEPSIS. Sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Manifestations 

may include lactic acidosis, oliguria, and an acute alteration in mental status. 

❑ SEPTIC SHOCK. Acute circulatory failure unexplained by other causes: SBP < 90 or MAP < 60. 

Reduction in SBP 40 mmHg from baseline despite adequate volume resuscitation. Patients who require 

inotropic or vasopressor support despite adequate fluid replacement are in septic shock. 

❑ 

OTHER: __________________________________________________________________________________ 

If you are the licensed treating physician, check here if you do not agree with this query: _________________ 

________________________________________ 

Physician signature 

Thank you for your prompt attention to this matter. If you have any questions, please contact the CDS nurse. 

CDS nurse: ____________________________________, RN 

Office telephone number: ___________________________ 

Cell phone number: ________________________________ 

Source: Gloryanne Bryant, RHIA, CCS, CHW senior director, corporate coding HIM compliance, San Francisco. Adapted with permission. 



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