One of the possible factors that can drag down medical coder productivity after the ICD-10 deadline on Oct. 1 could be an increase in queries.
If physicians don't document the details that support the granularity of ICD-10 codes, medical coders will have the added work of writing queries and reading responses. It also means physicians will have to take time away from treating patients to answer the queries.
Medical coders can improve their queries to make them as efficient and useful as possible with these six steps:
1. Write in clear, concise and precise language: Medical coders write their own queries or rely on standardized templates. The templates could provide consistent language and lead to more consistent physician responses. But some medical coders may be able to write clear, concise queries without templates. If medical practices do use query templates, those need to be converted to ICD-10 language.
2. Use evidence specific to the case: Queries need to give the physicians enough information so they don't need the medical records. So make sure each query has: the condition or diagnosis that the medical record already cites, any data in the record or supporting documentation that pertain to the question being asked, and the actual question.
3. Do not ask leading questions: Instead of asking if the patient has a certain diagnosis, ask if the details in the documentation support a more specific or different diagnosis than what is initially documented. Sometimes multiple choice questions can be written to avoid being leading.
4. Include query in the clinical documentation: If the query is in the clinical documentation, it can support the diagnosis.
5. Start using ICD-10 language: Introduce physicians to ICD-10 terminology before Oct. 1 tol imrove clinical documentation and help find the right diagnosis codes. Also, ask for details now that support ICD-10 levels of specificity. This can help train physicians on using documentation that supports ICD-10 coding.
6. Avoid writing queries: Using ICD-10 terminology now is a good step toward improving clinical documentation. But a full clinical documentation improvement (CDI) program could lead to fewer queries being needed at all.
While more complete documentation seems like more work, it is preferable to creating more work later when a medical coder interrupts physicians to revisit a patient encounter.
If it starts now, it will keep working after Oct. 1.