ASC Coding Tip: How to Better Ensure Compliant Physician Queries

Querying a physician is a common, useful, and sometimes essential way to obtain necessary details for correct ASC coding and complete documentation. However, physician queries can easily slip into the realm of noncompliance. There are strict standards outlined by insurance payers for querying a physician, and if these standards aren’t met, you can face denials for insufficient documentation that doesn’t support your coding.

Coder Responsibilities

A compliant query starts with the coder, who should take the following steps:

• Queries should be submitted when the coder is unable to assign a code based on the current documentation. The coder can query a physician for missing information, conflicting documentation, or clinical history that affects the current procedure.
• The query should allow for an open-ended response from the physician whenever possible to avoid leading the physician toward a specific response.
• If multiple choice responses can be provided without leading the physician, then the choices also need to include additional options of “other” and “clinically undetermined” in the event that the choices do not include the correct answer.
• The query should include information to identify the patient, episode of care, and physician it is intended for.

Physician Responsibilities

Once the coder has submitted a query to the physician, the physician is now responsible for providing a compliant response.

Physician queries are required to be signed and dated by the operating physician. Electronic queries should have a verified electronic signature with a date/time stamp. Paper queries should have a handwritten signature from the physician and a date.

• If the date is missing or if the query is signed by a different provider, then the query is considered incomplete or noncompliant.
• The use of CPT or ICD-10-CM codes to answer a query is considered noncompliant. Written descriptions of diagnoses are required to assign a diagnosis code. Descriptive operative details are required to assign a CPT code.
• Per the AHA Coding Clinic 2nd Quarter 2008 and AMA CPT Assistant August 2000, dimensions from the pathology report should not be used for lesion excision size. The specimen can shrink or change during processing, so this is not an accurate representation of the size during the surgical encounter. Lesion excision size must be documented by the physician. If the physician is unable to provide the lesion excision size, then the coder will code to the smallest size.

Additional Compliance Guidance

A completed query becomes part of the patient’s legal medical record. If clarification or discussion of the query is required, the physician and coder should do that in a more informal manner. The query should only be used for question and answer. If medical records are requested by a third party, then the query should be submitted along with the operative report to act as an addendum to support the coding.

Remember: More documentation is better than not enough. A query should always work in the facility’s and physician’s favor to support the services provided and codes submitted.