New codes aren't the only thing on the syllabus for ICD-10 education.
Medical coders will have to reinforce some old skills and knowledge such as anatomy and physiology. It's also a good idea to get better at writing queries.
The Journal of AHIMA suggests writing a query when clinical documentation:
- "Is conflicting, imprecise, incomplete, illegible, ambiguous or inconsistent"
- Describes clinical indicators that don't clearly support the underlying diagnosis
- Includes clinical indicators, evaluation, and/or treatment that does not seem related to any medical condition or procedure
- Does not support or validate a diagnosis
- Does not support the present-on-admission indicator
The assumption is that physicians will struggle with a learning curve on how much more information is needed to document patient encounters after Oct. 1, 2014. There are four basic principles that medical coders need to embrace if they're going to coax — not coerce — specific information on patient encounters from physicians.
Be written in clear, concise and precise language
Some medical coders prefer to write their own queries so they can keep the queries concise. Others prefer standardized queries based on templates. The second option could lead to more consistent physician responses.
Note that if a medical practice or hospital uses query templates, those need to be converted to ICD-10-CM/PCS coding language:
- Use ICD-10 coding manuals and other industry references.
- Teams should consist of clinical documentation specialists, medical coders and physicians.
- Plan to break it into manageable chunks each week.
Whichever format, the queries need to be individualized and addressed to a specific physician. The medical coder needs to provide name and contact info with each query.
Contain evidence specific to the case
Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting and co-author of the CDI Pocket Guide, tells For the Record that queries need to have three things:
- The condition or diagnosis that the medical record already cites.
- Any data in the record or supporting documentation that pertain to the question being asked.
- The actual question.
The goal is to give the physicians enough information so they don't have to look up the medical records themselves. Require more than yes or no answers.
Don't ask if the patient has a certain condition. Ask if the details in the documentation support a more specific or different diagnosis than what is initially documented.
And multiple choice questions would not be considered leading questions as long as the options are medically reasonable.
Be part of the clinical documentation
The query and responses should be added to the medical record and time/date stamped.
Writing Effective Physician Queries (For the Record)
Physician queries in 2013 (ICD-10 Trainer)
Update queries to prepare for ICD-10-CM/PCS (ACDIS Blog)
Guidelines for Achieving a Compliance Query Practice: Includes many examples (Journal of AHIMA)