4 tips to ease task of querying clinicians on coding matters

by: Laura Evans Aug 30, 2018

When you must approach your physician with a coding question, keep these four points in mind to ensure an efficient response with a minimum of fuss, advises Erica Remer, MD, a nationally known expert in clinical documentation improvement (CDI):

You are not questioning their judgement; you are helping them get credit for taking care of complex patients.
At the same time, it’s best not lead off with how the query will impact reimbursement, Dr. Remer says. Instead, stress the need to clarify when the medical record is imprecise, incomplete, ambiguous or inaccurate, or leaves questions as to clinical validity, she explains. Also, you must seek clarification if medical necessity is not evident in the physician’s documentation.
Acceptable query formats include those that are open ended (though this may be the hardest for a provider to quickly decipher and respond to), multiple choice or yes/no questions, depending on the type of information you need. Remember, it’s important for providers to include the clinical rationale for their answers.
Remember that clinicians are short on time so make your query clear and concise so the provider can answer it quickly.

Editor’s note: Dr. Remer specializes in helping coders and their doctors improve communication with each other. She will share her insights, plus numerous examples of successful physician queries, during the keynote presentation at this year’s Advanced Specialty Coding, Compliance & Reimbursement Symposium, Oct. 15-17 in Orlando, FL.

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