Diagnosis queries have become an increasingly vital process to ensure adequate documentation and accurate coding. However, it is often challenging to obtain timely responses from physicians regarding queries.
For instance, the demanding schedules of physicians/providers make it difficult to find an appropriate time for discussions. Certain physicians/providers may also exhibit resistance or reduced cooperation when addressing coding queries, perceiving them as burdensome or intrusive. Consequently, this can lead to delayed or insufficient responses.
Other factors that can affect communication include the location and the use of different electronic health record systems.
Strategies for Effective Coding Query Communication
To overcome these challenges, home health agencies can employ the following strategies:
- Establishing streamlined communication channels for coding queries, such as secure messaging systems, dedicated email addresses, or direct phone lines
- Collaborating with physicians to establish mutually agreed-upon timing and processes for querying, including assigning responsibility for contacting physicians and setting time restrictions for query submission
- Utilizing concise and specific queries that emphasize essential details and require minimal effort to respond
Agencies can use the following examples as a guide to writing queries that guide referral sources to provide additional information for accurate PDGM coding. These examples can also serve as references for creating other diagnosis-specific query tools. (Source: Axxess Home Health)
EXAMPLE 1
A patient has been referred to home health for wound care on the right great toe. The clinical documentation describes the need for “home health nursing for wound care of open wound of the right great toe.” However, the assessing clinician notes specific details such as the wound’s pale color, punched-out appearance with round edges, absence of hair growth on the lower extremities, and tight, shiny skin on both legs. The patient also experiences pain when elevating the legs. As the coder, you are aware that official coding guidance prohibits the assessing clinician from determining the origin of the wound. Consequently, you must initiate a query to seek clarification from the physician.
Option A:
Dear ______________,
To provide proper care for our patient, Mr. X, a specific origin of the wound of the right great toe is needed. The assessing clinician documents the following findings:
• Punched-out appearance with even, round wound edges
• No hair growth on the lower extremities
• Skin is tight and shiny bilaterally
• Pain with elevation of lower extremities
What is the origin of this wound? Please document your response in the record below:
_____ A. Arterial insufficiency with ulcer
_____ B. Venous insufficiency with ulcer
_____ C. Diabetic ulcer
_____ D. Traumatic wound (please state type) __________
_____ E. Other: Please specify ______________________
_____ F. Clinically undetermined
Provider Signature: _________________________________
Date: ______________________
Option B:
Dear ______________,
To provide proper care for our patient, Mr. X, a specific origin of the wound of the right great toe is needed. The assessing clinician documents the following findings:
• Punched-out appearance with even, round wound edges
• No hair growth on the lower extremities
• Skin is tight and shiny bilaterally
• Pain with elevation of lower extremities
Is this wound a non-pressure ulcer caused by arterial insufficiency due to atherosclerosis?
Please document your response below:
_____ YES
_____ NO, the underlying condition is: _____________________________________________
Provider Signature: _________________________________
Date: ______________________
EXAMPLE 2
A patient has been referred to home health for skilled nurse (SN) and physical therapist (PT) care following an acute hospitalization due to COPD exacerbation and Pneumonia. The provider’s referral and face-to-face documentation state that the SN is responsible for teaching the patient about new medications and nebulizer use and care, while the PT is to address weakness. During the PT evaluation, the therapist records 3-/5 muscle strength in the right lower extremity and notes generalized weakness. However, you know that codes for muscle weakness and generalized weakness are categorized as symptom codes and should not be used without an underlying specific condition. Notably, the assessing clinician mentions the patient’s self-reported history of a stroke two years ago, resulting in right-sided paralysis. However, no supporting documentation regarding the stroke is found in the facility or provider records. As the coder, you recognize that the patient’s statement alone would not justify a diagnosis of post-stroke weakness. Thus, it is necessary to initiate a query to the physician for clarification.
Option A:
Dear ________________,
Mrs. G was recently referred to a home health PT for treatment of weakness following an acute hospital stay for COPD Exacerbation and Pneumonia. The therapist reports 3-/5 manual muscle strength on the right lower extremity and documents the patient’s reported history of stroke two years ago with (R) hemiparesis. What is the cause of the weakness the PT is treating?
Please document the cause in the record below:
_____ Deconditioning
_____ Sequela of stroke with (R) hemiparesis
_____ Other condition (please specify) __________________________
Provider Signature: _________________________________
Date: ______________________
Option B:
Dear ________________,
Mrs. G was recently referred to a home health PT for treatment of weakness following an acute hospital stay for COPD Exacerbation and Pneumonia. The therapist reports 3-/5 manual muscle strength on right lower extremity and documents patient reported history of stroke 2 years ago with (R) hemiparesis. Is the cause of the weakness PT is treating sequela of stroke with hemiparesis?
Please document response in the record below:
_____ Yes
_____ No
_____ Other: __________________________________
Provider Signature: _________________________________
Date: ______________________
