Four needed elements in ICD-10 queries
There should be no question anymore. ICD-10 codes need to be as specific as as possible. But Stephanie Ellis of Ellis Medical Consulting in Franklin, Tennessee, has found that missing specificity is a common coding error:
"You can't code an unspecified cataract of an unspecified eye — you have to code the exact type of cataract and on which eye the surgery was performed."
But if that specificity is not in the clinical documentation, then medical coders need to follow up with queries. And that's going to create friction in the coding process. Medical coders could craft better queries that elicit the needed information in an efficient manor by following these guidelines:
Write in clear, concise and precise language
Medical coders write their own queries or rely on standardized templates.
The templates could provide consistent language and lead to more consistent physician responses. But some medical coders may be able to write clear, concise queries without templates. If medical practices do use query templates, those need to be converted to ICD-10 language.
Use evidence specific to the case
Queries need to give the physicians enough information so they don't need the medical records. So make sure each query has:
- 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.
Do not ask leading questions
Instead of asking if the patient has a certain diagnosis, ask if the details in the documentation support a more specific or different diagnosis than what is initially documented. Sometimes multiple choice questions can be written to avoid being leading.
Include query in the clinical documentation
If the query is in the clinical documentation, it can support the diagnosis.
While more complete documentation seems like more work, it is preferable to creating more work later when a medical coder interrupts physicians to revisit a patient encounter.