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- It is important for the CDI/coder to understand the role of the physician query. It is important that the CDI/coder knows when to generate a query. A query should not be used because of a lack of knowledge about a disease process or the performance of a procedure. It is the coder’s responsibility to do their due diligence before querying the physician. In today’s coding environment the physicians are being overwhelmed with unnecessary queries. We should not be querying the physician when we have a coding directive in the form of coding guidelines or guidance from the coding authorities. We should understand that the physician documentation will not always mimic the coding guidelines or a Coding Clinic verbatim. We as CDI/coders must put on our critical thinking hat on and be able to work through the documentation and apply the coding guidelines.
- Query when the documentation meets any the following:
- Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
- Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
- Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
- Provides a diagnosis without underlying clinical validation
- Is unclear for present on admission indicator assignment