In healthcare field, it is a common phrase "If you didn't write it, it did not happen". Any missing or incomplete piece of information results into incomplete codes and affects the reimbursement process. As part of my Intermediate Coding class, I learned that physician query is one of the important piece to complete of coding process for accurate reimbursement.

To become efficient coder, I need to be aware of key data sets that is required for each scenarios and if it not present, I need to query physicians to get the specific data points. These queries can be initiated by the coder or CDI professional who is responsible for maintaining high degree of data quality.

As part of the physician query assignments, I learnt how to abstract missing documentation, how to raise the query to respective physicians for clarification and substantiation. I learned that query should be always consistent, simple, on-point and non-leading.

I also learned about the CDI, which captures the quality of the patient encounters & EHR to reflect the real services that were rendered. CDI specialist acts as a liaison between the providers and the coding team and helps to translate patient's clinical status into coded data. With the deep knowledge of ICD-10-CM and PCS code assignments, they validate the correct sequencing of MS-DRGs as well as the CC/MCC codes to determine if they are supported by the required documentation. In my inpatient and outpatient case studies, I was able to query key information to assign correct codes, DRG & POA.

Artifacts:

Coding abstract - physician query assignments.