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Appendix B: Query Escalation and Retention

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2018












Whatever the size and structure of the practice, and regardless of who is responsible for the query, general practices for escalation and retention should apply.

Timeframes


A pre-visit review of documentation may be usefu....

Appendix C: Query Examples

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2018











Example #1: Diagnosis is documented but is not clinically validated




Dear Doctor,


COPD exacerbation is documented within the clinic note dated 3/5/xx.


There is no documentation in the current h....

Appendix A: Query Monitoring/Auditing

Author: AHIMA

Source: Journal of AHIMA

Publication Date: July 2018












Physician practices vary greatly in terms of number of physicians, size of staff, type of setting, management structure, and even whether they have CDI and/or credentialed coding professionals. As the healthcare industry moves toward population....

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