4 reasons for medical coders to query a provider about documentation

By Kelly Gooch for Becker’s Hospital Review

With documentation queries to providers, it is important for coding professionals, clinical documentation improvement professionals and other healthcare professionals to know the most appropriate times to query, according to a post on the American Association of Professional Coders website.

The post — written by Vicky Schack, compliance program manager-educator/auditor for Memphis, Tenn.-based St. Jude’s Children’s Research Hospital — references a brief from the American Health Information Management Association and cites the association’s reasons for queries.

The American Health Information Management Association’s reasons to query include:

  • To clarify why a patient was hospitalized
  • To get clarification when a documented diagnosis does not appear to be clinically supported
  • To clarify the intention and extent of care provided
  • To resolve situations in which there is conflicting documentation between the attending provider and other treating providers
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