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What to Know About Physician Queries in Medical Billing

As a medical billing professional, if you find you still have money on the table or procedures that were under-coded, you may need to do a physician query. Why? Because if poor documentation is the cause of money being left on the table, then you need to communicate with the physician to find out what may be missing in the record.

How to know when a physician query is necessary

When you ask for clarification, you’re performing what is known as a physician query. A physician query is necessary when you encounter an implied procedure or a missing procedure:

  • Implied procedure: In this situation, a procedure may be listed in the heading of a record, but it’s not documented in the body of the record.

  • Missing procedure: A missing procedure is one for which a diagnosis is listed but no treatment is noted.

The missing or implied procedure may have been a result of the physician being interrupted during dictation, or it may be an error in transcription. Most physicians and facilities use transcription services. The physician dictates, and the transcriptionist listens to the dictation and types the words into a document. Sometimes the transcriptionist uses templates and fails to import the correct one.

Other providers use voice recognition software. The physician dictates, and the words are entered automatically into a document. These notes have frequent errors, and clarification of the medical record is important for legal reasons.

If you work with a particular physician for an extended time, you’ll be so familiar with what the doctor does and how he does it that you’ll essentially be “in the doctor’s head” every time you read the documentation. It’s vitally important that you remain cognizant of the need for clear documentation and are careful about not coding a procedure that likely was done but is omitted from the documentation.

How to conduct a physician query

A physician query is simply a note to the physician that asks for clarification of the record. Some offices have a query form you can use to seek clarification when a procedure has been implied or is missing. Many of these forms, which are common in hospitals or large offices, list the most common omissions and a line for “Other.” You simply check the box you need more information for.

If you work for different providers, you need to familiarize yourself with the various query procedures of each office. If you’re working with a small office or practice, you can leave the note or chart in question on the physician’s desk with a note that says something like: “Which arm was it?” or “How large was the lesion?”

In other practices, you can simply ask the physician a non-leading question, and the provider will then dictate an addendum to the record that clarifies or corrects the issue at hand. Knowing how to approach the physicians now can help you produce sparkly clean claims later.

When you ask a physician for clarification about a record, beware of putting words in the doc’s mouth. Any and all clarification about records must come straight from the physician — not you. Don’t make assumptions about what he meant. Question the documentation, but don’t lead. Here are some examples of good versus bad queries:

Instead of This Say This
It was the left arm, correct? What arm did you perform the procedure on?
Was the tumor more than 5 cm? How large was the tumor?
Did you excise more than 1 cm of clavicle? How much clavicle was removed?
Did you debride to bleeding bone? How extensive was the debridement?
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