The physician query is a communication tool used by the coder in cases where there is incomplete or conflicting documentation. Discuss how you would educate physicians on documentation to support the diagnosis and treatment.

Complete assignment: LP09.1 Assignment: Physician Query: Directions: The coder should query the physician when documentation in the patients record is not sufficient to support the diagnosis in the medical record. The physician query form is a method of communication between the coder and the physician to address documentation that is not sufficient to support the diagnosis. Case Scenario: Patient: Sally James DOB:10-14-1960 MR#123-34-78 Admitted: 01-03-XX Physician: Ervin Mass The impression on the pathology report, ovarian cancer is documented; however, only ovarian mass is documented in the final discharge statement by the provider. Develop a physician query form that addresses incomplete or insufficient documentation in the case scenario listed above. The query form must include the following: 1. Patient Identification Information 2. Date of Service 3. Coders Name & Contact Information 4. Query Date 5. Name of Physician 6. Statement of the issue (as it relates to incomplete, vague or insufficient documentation) It is recommended that queries be written with precise language, identifying clinical indications from the health record and asking the provider to make a clinical interpretation of these facts based on his or her professional judgment of the case. (AHIMA)

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