tci Medicare Compliance & Reimbursement - 2022 Issue Q3

Documentation: Bolster Clinical Notes With This Query Insight

Utilize query guidelines to help with coding choices. A patient’s medical record is a legal document that tells the story of why that patient is being seen by a provider. However, some provider documentation is incomplete and needs a follow-up to confirm any conflicting, contrasting, or ambiguous information in the medical record. Learn how to use different query types to clarify the provider’s documentation. Seek Clarification Through Queries A patient’s medical record should show what tests were ordered, what tests were performed, and the provider’s thoughts as to what was wrong with the patient at...

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