Clinical documentation is the foundation of the health record, while the conversion of this narrative description into codes serves as the basis for reimbursement, quality reporting and other administrative and research activities. While documentation is often adequate from a clinical perspective, payer requirements, quality programs and government regulations often dictate specific requirements for reimbursement.

Radiologists are well-versed in clinical communication, but they typically do not have the knowledge of radiology coding guidelines, compliance and regulatory requirements that a radiology coding specialist does. Coders cannot make assumptions about discrepancies in the documentation. They subscribe to the adage, “If it wasn’t documented, it wasn’t done.”

Physician Query System

Without clarification from the radiologist, a coder must code to the documentation, which can result in lower reimbursement, compliance risk or denials. By establishing a communication channel between coder and physician with communication protocols and agreed procedures, you can create a collaborative workflow that supports organizational objectives. A well-defined and executed physician query system can break down the communication barriers, support compliance and promote accurate, timely reimbursement.

Physician Queries may be made in these situations:

• When there is conflicting, ambiguous, incomplete or unclear information in the report
• When further specificity is needed to accurately reflect the service performed, acuity, severity and/or occurrence of events
• To determine the significance of abnormal operative, procedural, pathologic, radiologic or other diagnostic findings

Some common documentation issues include:

• CTA ordered, but 3D not documented
• Doppler ordered, but spectral analysis not documented
• Inconsistent number of views between the radiologist’s interpretation and the report header
• No valid diagnosis, need for reportable signs or symptoms
• Appropriate body parts are not properly enumerated, etc.

Performing queries as a regular part of the coder workflow (pre-bill) improves billing accuracy, decreases denials and reduces the need for retrospective (post-bill) queries, which open the door to audit opportunities.  In response to a query, the radiologist can create an addendum to the medical record or advise the coder to code to the existing documentation. The addendum, when needed, provides clarification, enables appropriate code assignment and supports data integrity in reporting of diagnoses and procedures.

Tips for a Successful Program

The most effective query systems are those that are actionable, timely and consistent. An electronic query with physician reminders is a contemporary solution that promotes collaboration and flexibility. Physicians receive queries on a timely basis, which helps shape behavior. They can respond remotely at their convenience quicker and easier than manual methods or email. Automatic reminders keep the process on track so billing can be executed with minimal lag time.  To ensure queries are used appropriately, develop guidelines and train coders how to apply them. Queries cannot be leading or introduce new information. They should not elicit yes/no responses; questions should be open-ended to gather required information. Poorly written queries can undermine and derail the process. Develop templates for your most common queries to normalize communication with physicians and save time for coders.

Monitor, Measure and Manage Change

Internal monitoring should maintain the integrity of your query program. An internal audit can confirm that queries are not based on assumptions, are structured according to your protocols, do not question a physician’s clinical judgment and are not leading in nature. Appropriateness is vital to ensuring the collaborative spirit of the process and keeping physicians engaged.  The capability to measure the process and outcomes is a natural byproduct of an electronic physician query system. You can quantify the ratio of reports that result in queries, as well as response rate, turnaround time, and positive vs. negative responses. The quantitative data and concrete examples from the query process can help get physicians engaged by demonstrating the requirements and value of accurate documentation.

ICD-10 will increase the need for specificity, especially with regard to laterality, acute vs. chronic conditions, exact location of the condition and encounter type – initial/subsequent. Referring physicians will need to provide more specific and complete information; and registration staffs will be tasked with collecting more history than they capture now. Query reports will help you demonstrate to other stakeholders how their roles in the documentation process impact coding and reimbursement.

A query system is not a substitute for effective documentation. It is a tool to help keep the process on track. It should be accompanied by regular physician in-service sessions and periodic management feedback to support proactive documentation improvement. An ongoing and comprehensive program of training and timely feedback will support accurate, efficient code assignment that can improve revenue realization and accelerate your cash flow.