Physician Queries Handbook: Guide to Compliant and Effective Communication

The key to getting the medical record clarified and the information required to code properly is learning how to draft an effective, non-leading query to the physician.

The Physician Queries Handbook is the authoritative source for defining policies, procedures, and best practices for physician queries.

Coauthored by a physician, and CDI professionals with nursing, coding, and HIM backgrounds, the Physician Queries Handbook provides practical, tips and best practices for querying physicians on a concurrent or retrospective basis. It also presents strategies on how to develop a query policy and procedure that takes into account the many different facility-specific topics that directors and managers must understand.

Turn words into actions

Although Coding Clinic, AHIMA, and the ICD-9-CM Official Guidelines for Coding and Reporting provide guidance related to query policies and procedures, there are still a lot of gray areas for which hospitals must account, such as:
€ Who should leave queries?
€ What is a leading query?
€ How long should staff expect to wait for a query response?
€ How should hospitals deal with reluctant physicians?

Take a look at the topics covered in the Physician Queries Handbook:

CDI program basics and the query process
€ Enlisting internal facility support
€ Developing query roles
€ Defining CDI program organizational structure

Query process infrastructure
€ Prospective, concurrent, and retrospective queries

How to construct physician queries
€ Query format
€ Verbal vs. written queries
€ Leading queries
€ Query timeframe
€ Best practices

Performance monitoring
€ Coder/CDI productivity and quality
€ Program effectiveness

Physician techniques
€ Interviewing physicians
€ Common scenarios
€ Building relationships
€ Disruptive physicians
€ Joint Commission rules
€ Medical staff procedures

Appendix
€ ACDIS physician query benchmarking survey
€ AHIMA physician query practice brief
€ ICD-9-CM query rules
€ Coding Clinic references
€ Sample query forms