A query is a communication between the provider (Physician) and Medical Coder to clarify documentation in the health record for documentation integrity and accurate code assignment for an individual encounter in any healthcare setting.
A query will include information like; Patient name, Admission date and/or date of service, Medical record number, Date query initiated, Date query answered, Name and contact information of the individual initiating the query
A query should have statement of the issue in the form of a question along with clinical indicators specified from the patient’s record.
Types of Query:
POA query, Ruled in /ruled out query, Clinical significance query, Cause and effect query, Conflicting documentation query, CHF acuity and specificity query, Debridement type and depth query.
