COMPLETE WITH INSTRUCTIONS
WK4 QUESTION3 HP-216
Instructions: Provide the most correct response.
Question
One of the guidelines for effective physician queries is:
· Questions need not be supported by clinical findings
· You may introduce any new information not contained in the record
· You can present the impact to reimbursement
· Do not provide leading information
Physician queries are acceptable in what format(s)?
· Multiple Choice
· “Yes”/”No”
· Open Ended
A patient is admitted from the ED with signs and symptoms of infection, including fever and elevated WBC. The admitting diagnosis is UTI with suspected sepsis. Possible sepsis is noted on the H&P and the infectious disease consult. Progress notes initially include “sepsis”. The blood culture comes back negative, however, and following this, the diagnosis of sepsis continues to be documented on the progress notes as these are copied-and-pasted from day to day. The Discharge Summary documents “UTI—sepsis was ruled out”.
A physician query would be appropriate in this instance.
· True
A patient develops anemia following a major surgery. The OR states that there was some bleeding; however, there were no additional procedures performed to control the bleeding that would not otherwise have been done. The patient was transfused, though, and serial H&Hs were followed throughout the remainder of the admission. Fluid overload also developed during the admission, around the same time as the patient was transfused. The final diagnosis on the Discharge Summary is simply “anemia”. The body of the Discharge Summary attributes this to hemodilution from IV fluids.
A physician query would be appropriate in this instance:
· True
Patient admitted with 5 days history of nausea and vomiting. Chest X-Ray indicates left upper lobe pneumonia. Antibiotics ordered.
Proposed Query:
Is the patient’s pneumonia due to aspiration?
Is this physician query appropriate, and, if not, why not?
· Appropriate
· Not appropriate, contains a leading question
· Not formatted correctly
·
Appropriate with formatting for physician response
Instructions: Provide the most correct response.
Question
Diagnosis of hypokalemia is documented in the progress note; labs indicate a potassium of 3.8
Proposed Query:
Please clarify the status of this diagnosis by documenting your response below
___ Hypokalemia was ruled out
___ Hypokalemia is valid diagnosis for this encounter
___ Hypokalemia was clinically insignificant finding
___ Unable to determine
___ Other (Please specify): ________________
Is this query appropriate, and, if not, why not:
· Appropriate
· Not appropriate, leading question
· Not appropriate, as appropriate choices are not included
Clinical indicators that were not included in the record were includedProstate mass is documented in the final discharge summary by the provider; however, the pathology report specifies prostate cancer.
Is a query appropriate and, if not, why?
· Appropriate
· Not appropriate, pathology report is always the definitive statement
· Not appropriate, the final discharge diagnosis by the physician is the definitive statement
·
Coding guidelines indicate when both diagnoses are listed, either may be assigned
Wound care nurse states “new stage 3 pressure ulcer, right knee, not noted at time of admission to hospital”
Would a physician query be appropriate in this instance, and, if not, why not?
· Appropriate
· Not appropriate, clinical indicator has been provided appropriately
· Not appropriate, as diagnosis given is appropriate to be coded
·
Not appropriate, no additional information is needed for coding purposes
Patient comes in with a fractured hip with plans to undergo a total hip replacement. At the time of CDI review, the physician has not documented any further specificity regarding the hip fracture. An X-ray was ordered for the right hip, and the radiology report describes the location of the fracture as intertrochanteric.
Is a query for clarification of laterality and specific location of the fracture be constructed?
· Yes, the coder should always code to the highest level of specificity, so this information will be needed to do so.
· Yes, the radiology report cannot be utilized for capturing this information.
· No, the radiology report cannot be used as the sole documentation, however, can be used to support coding to a greater level of specificity.
· Yes, the coder should utilize the radiology report as the supporting clinical indicator for the query.
Yes, the coder should utilize the radiology report as the supporting clinical indicator for the query.
What essential elements should be included in a physician query?
· Diagnosis or condition that requires clarification listed where the information is found throughout the record
· List of clinical indicators
· How diagnosis needs to be further clarified
