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Central to the query form debate is how coders can ask physicians about incomplete documentation. With recent reimbursement and regulatory changes, however, coders may be surprised to find more physicians asking questions of them, says LaVonne Wieland, RHIT, consultant, enVision Group, Naples, FL. "It’s not just the coders initiating the communication," she says.
Overall communication between physicians and coders has improved over the years, but many coders are so intimidated by physicians that they don’t want to talk with them, she says. Wieland recommends providers take steps to promote communication. "Sometimes it starts by just using a query form," she says. The form tells the physician what is missing and asks him or her to add the information to the documentation. "Once you start building from that type of relationship, the physicians start coming back and communicating to you."
Wieland had that experience when she worked as an inpatient coder in the 1980s. "It got to the point where a couple of the surgeons — if they had a case that was a little bit different from something they have done before — would sit down by my desk and say, This is what I did. What order should I dictate it in? What do you need to know to code it appropriately?’
"They were seeking me rather than the other way around," she continues. "They were tired of getting little notes asking them questions. To be proactive, they just started coming to me."
To facilitate communication, Wieland recommends scheduling meetings, monthly or quarterly, between the coders and physicians. The meetings do not always have to have the same format. For example, physicians can attend coding staff meetings to explain a new procedure. Or physicians can speak to coders about what they do in an area in which the coders are having difficulty. "I call it a disease process education seminar," she says. "The goal is to start communicating with the physicians," she adds. "Coders shouldn’t feel that they couldn’t ask physicians a question."
The discussion may yield more long-term results than immediate ones, Wieland says. "When you look back, you will realize how much easier it is to communicate with the physicians or that you are now getting the information because you have told physicians what you need to know."