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Tips for Querying a Physician to Improve HCC Coding Accuracy

Tips for Querying a Physician to Improve HCC Coding Accuracy

What is a Physician Query?

The American Health Information Management Association (AHIMA) defines a physician query as “a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment for an individual encounter in any healthcare setting.”

As more medical groups move towards concurrent HCC coding review processes, physician queries have been an increasingly important process to ensure accurate HCC coding. However, querying physicians while adhering to compliance can be a complex process.

Working with many organizations, we’ve learned the first step is always creating organizational policies and procedures for the query process. Query practices then need to be managed and monitored for compliance and tracking. Once in place, provider education about the importance of queries is needed to drive adoption and responsiveness.

Know When to Query a Physician

According to AHIMA guidelines, coders should only query a physician when the documentation:

  1. Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent.
  2. Provides a diagnosis without an underlying clinical validation.
  3. Includes clinical indicators, diagnostic evaluations, and/or treatments that are not related to a specific condition or procedure.
  4. Has unclear clinical indicators.

If one or more of the above conditions is met, a physician query may be necessary.

Dos and Don’ts of Querying a Physician

A physician query must be clear and concise. It should contain clinical indicators from the health record. According to AHIMA guidelines, these clinical indicators should be specific to the patient and episode of care, support why a more complete or accurate diagnosis or procedure is sought, and support why a diagnosis requires additional clinical support to be reportable. Additionally, the query should present only the facts that identify why the clarification is needed.

Physician queries should not steer the provider towards a specific diagnosis or procedure. They should also never indicate the impact on reimbursement, payment methodology, or quality metrics.

When a compliant query process is successfully implemented, the benefits of the more accurate and specific coding are quickly realized in terms of addressing care gaps. The working relationship between the coder and physician often creates educational opportunities that improve coding completeness and specificity.

For example, coders often employ a cause-and-effect query to clarify in the progress notes (based on medical judgement) whether two conditions, such as Diabetes and CKD, are related to each other. The query always allows for a response of none or not applicable.

Free download: HCC Coding Smart Rules

Compliant Physician Query Example and Components

All queries should contain the following components:

  1. Provider name
  2. Site name
  3. Member name
  4. Member DOB
  5. Date of Service


Good morning Dr. X,
RCxRules is prompting for review. Upon looking at your note for [Member Name, DOB, Date of Service], I see that you coded C67.2 – Bladder CA and C61 – Prostate CA. When I looked at the notes from Hematology/Oncology, [dated xx/xx/2020] they are using the “History of” codes (radiation therapy completed in 2015). Would it be appropriate to change the codes to Z85.51 – History of Bladder CA and Z85.46 – History of Prostate CA? Please let me know.

The above query example allows for documentation updates and provides clear instructions for resolving the query.

Tips for Successful Physician Queries

Work with your providers to develop and agree on timing and processes for querying. For example, determine who is responsible for querying physicians and outline timing restrictions (the number of days from the date of service in which a query can be sent to a provider). It’s usually better to query a provider as soon as possible—typically groups are unable to hold charges for longer than five days before sending out claims. Our customers have noted that queries coming from co-workers and internal resources are often better received than those coming from a payer or vendor.

How the RCxRules HCC Coding Solution Can Help

The HCC Coding Solution not only identifies charges that may be eligible for physician queries, but enables groups to hold charges for their requested amount of time to allow for the query process. Groups are then able to adjust diagnosis codes based on outcome of the query before the charge is released to billing. The in-house software allows co-workers, rather than outside resources, to conduct the queries.

The concurrent approach enables real-time feedback to providers, so they’re able to adopt best practices sooner and have a better understanding of the query in question since the visit was more recent. It also lessens the need for a retrospective process and the back-and-forth correspondence with payers that retrospective reviews typically entail.

Querying providers is an efficient method to ensuring accurate HCC coding, which will lead to improvements in risk adjustment performance and more accurate reimbursements. Set up a 15-minute meeting to learn more.

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