Q: How should we appropriately query the physician to support diagnosis coding for PDPM reimbursement?

A:With only a few exceptions, ICD-10-CM code assignment must be based on documentation by the patient’s provider that a specific condition exists. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification when coding an active diagnosis. 

The American Health Information Management Association defines an official query as a question presented to a healthcare provider to gain additional documentation so the HIM professional can more accurately assign a code or codes. CMS supports the use of query forms as a supplement to the healthcare record. Be wary of telephone or verbal orders for diagnoses that don’t do enough on their own to adequately describe clinical indicators and reasons behind diagnosis assignment.  

Establish processes including record review promptly after admission to identify gaps in documentation and formally query the provider if information is ambiguous, inconsistent or missing specificity.

The query process should not be used to gain “NTA points” or other reimbursements without evidence.When creating the query, include the patient’s name, date of service, date the query is initiated, name and contact information of the individual initiating the query, the patient’s background information and clinical data, and the open-ended, non-leading question. Follow up with the provider within 48 hours if the query has not been answered.  

Staff assigning diagnosis codes should be involved in coding accuracy monitoring processes, including review of documentation to support the condition(s) as active.