HCPro, JustCoding Inpatient - 2016 Issue 11 (March)

Q&A: Clarifying inpatient query expectations

March 22nd, 2016

Q: Can you clarify the expectations related to documenting the discussion between a physician and a clinical documentation improvement specialist when a query is done verbally? The 2013 ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice expanded on the need to document this interaction and we’re wondering if our process is compliant.

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