Billing and Coding: The Secrets of Effective Queries

Queries are a vital part of the medical billing and coding process for both informational and compliance reasons. Even so, many professionals struggle with knowing exactly when to request additional information and how to structure the query so that it is effective, compliant, and maintains a good working relationship with the provider. Documentation is a shared responsibility; whereas the provider’s side of the equation involves ensuring that the information they provide is sufficient for coding and reimbursement purposes, the coder’s side involves recognizing when there is a need to query and doing so in a way that resolves any potential issues.

Minimizing the need

When a report or requisition doesn’t meet requirements, billing and coding professionals may find themselves needing to query the ordering physician—a task that is easier in some environments than others. “If I’m in a hospital or clinic location where I have immediate access to a provider and to medical records I can access and review, it’s not difficult to obtain additional information—and I can pull it together quickly if needed to respond to an audit,” says Robin Zweifel, director of Coding and Billing Compliance at BioReference Laboratories and editor-in-chief of the American Pathology Foundation’s Pathology Service Coding Handbook. But for billing and coding professionals working in other settings, querying a diagnosis code or requesting more information can be a more challenging prospect. “Many of our pathologists are not in a hospital setting or not directly connected to the hospital’s medical records,” Zweifel explains. “Some work in independent reference laboratories, which means we have no access to additional medical records. That can make it hard to include all the necessary information in the interpretive report.”

In these types of situations, Zweifel recommends requesting as much information as possible on requisitions or physician orders. This ensures that meaningful details are readily available as soon as the laboratory receives the specimen—although it doesn’t eliminate the need for a robust follow-up process for queries. “If I’m billing for services and my documentation is not optimal, and then a few years later that record is selected for an audit, it will be difficult for me to go back and query for details. At that point, I may no longer have a relationship with that ordering provider or independent laboratory—so it’s always better to get as much information as I can right from the start.” Another approach Zweifel suggests is having a medical or evaluation management note accompany each requisition. That way, the information is already on file and can be referenced during an audit if needed. Although this creates more up-front paperwork—a challenge for busy laboratories—it prevents much greater challenges from arising during future reviews and audits.

Deciding when—and how—to query

Reasons for provider queries may include missing or ambiguous information (especially signs, symptoms, or indications for further investigation), inconsistent or conflicting information, lack of clarity or specificity, or other issues such as an extended inpatient stay or a need for a response to another physician’s diagnosis.¹ When ordering laboratory testing, providers must record the reasoning behind their decisions for clinical validation purposes. In many cases, a final diagnosis has not yet been made, so billing and coding professionals need to know what indications led the provider to order a given test. If that information is lacking or presented in a nonstandard way, queries may arise—and, because communication styles differ from one person to the next, the process may not always be smooth sailing.

“You may encounter situations in which you’re finding it difficult to communicate with a provider, but want to maintain the relationship with them,” says Zweifel. “From a laboratory perspective, we have a responsibility to educate. It’s important to find a way to communicate with those referring providers that is not disruptive to their day-to-day practice, but also lets them know why you are querying for additional details or documentation. I find that physicians often feel they’re being asked to give a final diagnosis. That’s not necessarily the case; we cannot lead them to document in specific ways or to provide specific diagnoses—and we understand that they’re seeking additional information from the laboratory test so that they can make a diagnostic decision. If a physician doesn’t have enough information to give a definitive diagnosis, we’re asking them to record the sign, symptom, indication, or complaint that led them to order a specific test.”

Quality queries

There’s no standard format for provider queries, but the American Health Information Management Association recommends that compliant queries include non-leading titles and statements, avoid using language that indicates uncertainty (such as “likely” or “probable”) unless necessary, and provide multiple-choice answer options that include appropriate clinical indicators.² However, not all authorities agree with the latter. AAPC, for example, suggests choosing between yes/no, multiple-choice, and open-ended questions based on the situation³—whereas healthcare coding consultant Terry Fletcher prefers to avoid yes/no questions altogether because of their potential to cause further confusion.⁴

Suggested phrasings for queries may include:

• “The medical record states that . . .” (quote to avoid introducing new information)
• “There is contradictory information in . . . Are you able to resolve the contradiction?”
• “Can you clarify . . .”
• “Can you specify . . .”
• “Is there a diagnosis connected to . . .”

What are the consequences of incomplete documentation? Zweifel explains, “Unfortunately, if an audit determines that the information is incomplete, the laboratory will carry a financial liability. The payer will recoup their payment for the service if they determine that the documentation to bill for that service is incomplete.” There is a window of time in which the lab can review its records to look for additional documentation that may not have been included in the claim submission or request further information from the ordering physician. “But the longer the time from initial order to query, the greater the risk that you won’t obtain that necessary information,” Zweifel cautions. “The more information you can query for within an immediate timeframe, the better.”

References:

1. Frady A. Q&A: Determining when coders should query for definitive diagnoses. Association of Clinical Documentation Integrity Specialists. January 11, 2018. https://acdis.org/articles/qa-determining-when-coders-should-query-definitive-diagnoses.
2. Guidelines for Achieving a Compliant Query Practice (2022 Update). American Health Information Management Association and Association of Clinical Documentation Integrity Specialists. December 14, 2022. https://ahima.org/media/51ufzhgl/20221212_acdis_practice-brief.pdf.
3. Miller A. Take Your Provider Queries to the Next Level. AAPC. July 1, 2022. https://www.aapc.com/blog/85344-take-your-provider-queries-to-the-next-level.
4. Fletcher TA. The Art of the Physician Query. ICD10monitor. August 13, 2019. https://icd10monitor.medlearn.com/the-art-of-the-physician-query.