McKnight's April 1, 2022
Q: How should we appropriately query the physician to support diagnosis coding for PDPM reimbursement?
A:With only a few exceptions, ICD-10-CM code assignment must be based on documentation by the patient’s provider that a specific condition exists. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification when coding an active diagnosis.
The American Health Information Management Association defines an official query as a question presented to a healthcare provider to gain additional documentation so the HIM professional can more accurately assign a code or codes. CMS supports the use of query forms as a supplement to the healthcare record. Be wary of telephone or...
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