When we need to query the Provider as per ICD 10 CM 2017 Guidelines

             Here are some examples of when the ICD-10-CM Official Guidelines for Coding and Reporting instruct coders to query:

When a Provider documents Urosepsis: 

 The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.

When coding complications of care:

“Query the provider for clarification, if the complication is not clearly documented.”

When a provider uses the term “borderline”:

“Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.”

When coding acute organ failure and sepsis and severe sepsis:

“If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.”

“Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.”

When coding acute respiratory failure:

“If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.”

When coding ventilator-associated pneumonia:

“If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.”

When coding pressure ulcers:

“If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.”

When coding acute traumatic versus chronic or recurrent musculoskeletal conditions:

“If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.”

When coding complication of kidney transplant:

“If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.”

When coding conditions present on admission:

“If at the time of code assignment the documentation is unclear as to whether a condition was present on admission or not, it is appropriate to query the provider for clarification.”

“Coders are encouraged to query the providers when the documentation is unclear.”
 

You should also query when you see an error or omission in the provider’s assignment of ICD-10-CM codes into the assessment in the electronic health record (EHR).