Q&A: Using open-ended physician queries

December 15, 2017
Medicare Web

Q: Our facility does not often use open-ended queries to physicians. Could you give an example of an open-ended query and any disadvantages they may have?  

A: An open-ended query works best when the potential answers are limited, when the query involves com­monly used terminology, and when physicians are familiar with the type of documentation required.

The following is one example of a possible open-ended query: “Dear Dr. Green: The patient’s sodium (Na) was 129, and the progress notes indicate ‘low serum sodium level.’ An order was written to place the patient on .9NS. Please clarify the associated diagnosis being treated.” In this scenario, the physician is likely to respond and document “hyponatremia.”

Sometimes an open-ended query can be problematic. For example, “Dear Dr. Smith, the patient’s progress note indicates he is being treated for pneumonia with vancomycin. Please clarify the type of pneumonia being treated.” Although the wording of this query does a great job of not leading, it may not result in the most clinically appropriate answer (i.e., methicillin-resistant Staphylococcus aureus pneu­monia).

In many cases, the physician will respond “bacterial pneumonia,” which will still lack the speci­ficity needed for coding purposes. Other physicians may respond “complex” or “severe” pneumonia. In such situations, the coder would have to issue a second query in an attempt to further clarify the issue.

Editor’s note: This question was adapted from the HCPro book The Coder's Guide to Physician Queries by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, with contributions from Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE.

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