For the best practice, use incomplete or otherwise confusing clinical documentation. Coders should assume that there will be a learning curve for physicians to submit more detailed patient encounters. Using problematic documentation for training will prepare coders for the reality of the ICD-10 transition.
Here are three ways ASC and medical practices can be sure to craft correct queries.
1. Use standardized templates. Standardized queries, as opposed to coders each writing their own, may lead to more consistent physician responses. Be sure to be clear, concise and precise.
2. Contain specific evidence. Be sure to include enough information so the physicians don’t have to look up medical records themselves.
3. Ask non-leading questions. Rather than questioning if a patient has a certain condition, ask if the details support a different diagnosis than was initially documented.
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