topic - pinson & tang€¦ · web viewmetabolic encephalopathy. toxic encephalopathy....

DOCUMENTATION CLARIFICATION QUERIES

These sample physician query documents are offered solely as examples of standardized physician queries to clarify clinical documentation within the medical record. These query documents were created based on our interpretation of AHIMA/ACDIS guidelines and may be used by healthcare facilities at their own discretion.

Pinson and Tang. LLC makes no representation, guarantee or warranty with respect to these query documents, including with respect to their compliance with any relevant state, federal or other guidance. It is the sole responsibility of the healthcare facility to review and modify these examples as needed to ensure they meet their own compliance policies and standards, as well as the standards of any applicable state or federal regulatory entity.

These templates are considered a copyrighted work under the United States and other copyright laws and the property of Pinson and Tang, LLC.

Healthcare facilities may make archival copies and customize this template only for the limited use of their facility or organization and not for resale or public sharing.

This template and any customized or modified version of this template may NOT be sold, distributed, published to an online gallery, hosted on a website, or placed on a public server.

If any questions regarding this limited use license, contact [email protected].

Recommendations for use: These query templates are designed for use as Word documents or e-messages and the content is to be edited and customized for the specific findings in each case. Suggested indicators not present in a particular case and/or multiple choice response options not supported by indicators (e.g., acute heart failure with only chronic indicators) should be deleted prior to submission to the provider. Content within brackets should be completed or deleted. Titles of each template are for reference only and should not appear on queries submitted to providers.

© 2016 Pinson and Tang, LLC. All Rights Reserved.

1

mailto:[email protected]

DOCUMENTATION CLARIFICATION QUERIESTable of Contents

Topic Page No.Acute Coronary Syndrome 3Acute Kidney Injury (AKI) 4Acute Tubular Necrosis 5Anemia, Acute Blood Loss 6BMI > 40 7BMI < 19 8Chest Pain 9CHF – specify type only 10CHF – specify type and acuity 11CKD Stage 12Debridement, Excisional 13Depression 14Diabetic Gastroparesis 15Diabetic Complications 16Encephalopathy 17Encephalopathy causing Delirium 18Functional Quadriplegia 19GI Bleeding 20HIV/AIDS 21Hypertension (Crisis / Emergency) 22Malnutrition, severity 23Malnutrition, not yet diagnosed 24Pathologic / Osteoporotic Fracture 25Pancytopenia 26Pneumonia, Healthcare Associated (HCAP) 27-28Pneumonia, Aspiration 29Pressure Ulcer 30Respiratory Failure, Acute 31Respiratory Failure, Chronic 32Schizophrenia 33Sepsis 34Syncope 35TIA 36Urosepsis 37Probable/suspected cause of symptoms 38Specific diagnostic condition 39Clarification of a conflicting diagnosis 40Confirmation of a diagnosis 41Clinical validation query 42General query template 43

2

[Acute Coronary Syndrome]

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having ACUTE CORONARY SYNDROME.

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following this condition is intended to indicate:

Transmural MI Subendocardial MI STEMI NSTEMI Unstable angina Other diagnosis (please specify) Not applicable / none of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.

[Acute Kidney Injury]

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having______________________________________________________.

3

The following lab is also documented in the medical record:

Creatinine on admission = _______ Baseline creatinine [if known]: _______

Correction of creatinine from ________ to ________ following rehydration

Creatinine increasing from _______ to _________ between ______ and _____ [dates]

Urine output ______ cc over ____ hours [if >6 hours and meets cc/kg/hr criteria]

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following these findings suggest:

Acute kidney injury (AKI) / acute renal failure

Acute on chronic renal failure

Chronic kidney disease / chronic renal failure (Please specify Stage)

Other condition

Not applicable / None of the above


4

[Acute Tubular Necrosis (ATN)]

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having Acute Kidney Injury (AKI).

Include the following clinical findings, as applicable, which support the query for ATN:

Prolonged elevation of creatinine (> 72 hours)

Oliguria (low urine output specified in cc/hr over what time period)

Hypotension (include specific blood pressure readings)

IV contrast administration

Nephrotoxic medication

The following is also documented in the medical record: Serial creatinine levels [and dates]: FENa = Urinary sodium concentration: Urinalysis [if applicable]: Other circumstances:

Based on your medical judgment, can you further clarify in the progress notes the likely cause of the acute renal failure or insufficiency in this case such as:

Acute Tubular Necrosis

Acute Cortical Necrosis

Acute Glomerulonephritis

Pre-Renal Acute Kidney Injury/Renal Failure

Another condition (please specify)



[Acute Blood Loss Anemia]

5

Documentation in the medical record indicates the following:

Anemia

Drop in Hgb from ___ to ___

GI bleeding

Hypotension

Blood transfusion of __ units

Other

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following conditions are responsible for these findings:

Acute blood loss anemia Chronic blood loss anemia Acute on chronic blood loss anemia Acute hemorrhagic anemia Iron deficiency anemia Other anemia (please specify) Not applicable / None of the above


6

[BMI >40]

Documentation in the medical record indicates that this patient has:

BMI =

Other documentation includes:

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following conditions are associated with this BMI:

Overweight Obesity Morbid obesity Other condition (please specify) Not applicable / None of the above


7

[BMI < 19]

Documentation in the medical record indicates that this patient has:

BMI =

Other documentation includes:

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following conditions are associated with this BMI:

Underweight Malnutrition – if so please document severity Undernutrition Anorexia Other condition (please specify) Not applicable / None of the above


8

[Chest Pain]

Based on the documentation in the medical record, this patient was admitted with

CHEST PAIN.

Other information in the medical records includes:

Based on your medical judgment, is the chest pain most likely, possibly, probably due to any of the following causes:

Coronary artery disease Pleurisy Biliary colic GERD/reflux Costochondritis Anxiety Dyspepsia Gastritis Hyperventilation syndrome Cholelithiasis Cholecystitis Chest wall pain Esophagitis or spasm Hiatal hernia Peptic ulcer Other diagnosis (please specify)

□ Not applicable / None of the above


9

[CHF – specify type only]

Documentation in the medical record indicates that this patient is being treated for

HEART FAILURE / CHF.

Echocardiogram reports EF of __________ An EF of _____ is documented [location / by whom]

The patient has a history of [ESRD / Hypertension / Coronary artery disease]

Medications include:

Chest x-ray shows:

BNP =

Other documentation and findings include:

Based on your medical judgment, can you further clarify in the progress notes the precise nature of the patient’s heart failure/dysfunction for this admission such as:

SYSTOLIC

DIASTOLIC

COMBINED SYSTOLIC/DIASTOLIC

Other (please specify)

Not Applicable / None of the above


10

[CHF – Specify type and acuity]


HEART FAILURE or CHF.

Echocardiogram reports EF of __________

An EF of _____ is documented [location / by whom] The patient has a history of [ESRD / Hypertension / Coronary artery disease]

Medications include: ___________________________________________________

Chest x-ray shows: _____________________________________________________

BNP = ________

Other documentation and findings include:

Based on your medical judgment, can you further clarify in the progress notes the precise nature and severity of the patient’s heart failure for this admission, such as:

Systolic

Diastolic

Combined

Exacerbation / Decompensation (Acute)

Acute on Chronic

Chronic


Not Applicable / None of the above


11

[CKD Stage]

Based on the clinical information documented in the medical record, this patient has been diagnosed with Chronic Kidney Disease, Failure or Insufficiency.

Lab reports show a stable GFR of ____ to ____ from _______ to ________.

Stage GFR

CKD Stage 1 > 90

CKD Stage 2 60 – 89



CKD Stage 5 < 15

ESRD Need for dialysis

Based on your medical judgment, can you further clarify the appropriate stage of CKD in the progress notes?


12

[Debridement, Excisional]

Based on the documentation in the medical record, this patient has undergoneWOUND CARE and/or WOUND DEBRIDEMENT.

Based on your medical judgment, can you further clarify the precise nature, depth, extent and/or methods of wound debridement utilized in this case, such as:

EXCISIONAL debridement (use of a scalpel/blade to cut away tissue) NON-EXCISIONAL debridement (chemical, scrubbing, trimming with scissors) Other debridement (please specify) Other / Not applicable / None of the above


13

[Depression]

Documentation in the medical record indicates that this patient has been admitted with or

diagnosed as having DEPRESSION.

The following is also documented in the medical record:

_________________________________________________________________________

Based on your medical judgment, can you further clarify in the progress notes the status of

this patient’s DEPRESSION:

Type

Major depression

Simple depression

Severity

Mild

Moderate

Severe

Remission status

In remission

Not in remission



In responding to this request, please exercise your independent professional judgment. The

fact that a question is asked does not imply that any particular answer is desired or expected.

14

[Diabetic Gastroparesis]

Documentation in the medical record indicates that this patient has been diagnosed withDIABETES and is being treated for [GASTROINTESTINAL disorder].

Additional findings also documented in the medical record include [include all that apply]:

Vomiting without diarrhea

Distended stomach

History of similar or repeated episodes

History of peripheral or autonomic neuropathy

Abdominal pressure or swelling

Treatment with Reglan (metoclopromide)

Other (please specify


Based on your medical judgment, can you further clarify in the progress notes a specific diagnosis, if any, related to these gastrointestinal symptoms/findings and the patient’s diabetes?


15

[Diabetic Complications]

Documentation in the medical record indicates that this patient has been diagnosed with

DIABETES and [the related complicating condition]

Additional findings include:

Based on your medical judgment, can you further clarify in the progress notes

whether or not the [related complicating condition] is due to diabetes? Other (please

specify)



16

[Encephalopathy]

Documentation in the medical record indicates that this patient has been diagnosed as having the symptom of ALTERED MENTAL STATUS. Additional findings also documented in the medical record include: [include all the apply]

Fever Infection Dehydration / electrolyte imbalance Sepsis / SIRS Hypoxia Hepatic / renbal failure Abnormal lab tests: Drug toxicity or adverse effect:

Based on your medical judgment, can you further clarify in the progress notes any underlying neurologic cause, condition or process, if any, represented by this symptom including:

Metabolic Encephalopathy

Toxic Encephalopathy

Toxic-Metabolic Encephalopathy

Coma

Other condition (please specify)



17

[Encephalopathy causing Delirium]

Documentation in the medical record indicates that this patient has been diagnosed as having the symptom of DELIRIUM. Additional findings also documented in the medical record include: [include all that apply]

Fever Infection Dehydration / Electrolyte imbalance Sepsis/SIRS Hypoxia Hepatic/Renal Failure Abnormal lab tests: Drug toxicity or adverse effect:

Based on your medical judgment, can you further clarify in the progress notes the underlying cause, if any, of delirium including:

Metabolic encephalopathy

Toxic encephalopathy (drugs / toxins)

Toxic-Metabolic encephalopathy

A mental illness / disorder (please specify)

Circumstantial stress and/or sleep deprivation




18

[Functional Quadriplegia]

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having: [include all that apply]

Severe dementia Total care Activity level: Bedfast Mobility level: Completely immobile, or very limited Feeding tube Extreme / severe neurologic deficits Urinary / bowel incontinence Flexion contractures Other severe disability condition:

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following do the above conditions indicate (more than one if appropriate):

Functional Quadriplegia

Quadriparesis

Coma

Severe debility only

Paralysis


Not applicable / None of the above/


19

[GI Bleeding]

Documentation in the medical record indicates that this patient has been identified to have and/or is being treated for GI BLEEDING.

EGD / Colonoscopy findings: __________________________________________________

___________________________________________________________________________

Other information in the medical record includes: __________________________________

Based on your medical judgment, can you further clarify in the progress notes whether or not the GI bleeding is due to the [lesion(s) identified] ?

Other cause of GI bleeding (please specify)



20

[HIV/AIDS]

Documentation in the medical record indicates the patient has:

HIV [or HIV “infection”] and

Current and/or prior CD4+ T-lymphocyte count of ________ and/or a history of the following conditions:

Based on your medical judgment, can you further clarify the HIV status of this patient:

HIV positive only / HIV infection (without AIDS)

HIV disease (AIDS)

Other condition (please specify)



21

[Hypertensive Crisis / Emergency]


Hypertension

The following is also documented in the medical record :

Systolic BP consistently in the range of ___ to ___ from [dates]

Diastolic BP consistently in the range of ___ to ___ from [dates]

Other clinical findings [list any symptoms, diagnoses or evidence of organ dysfunction that might be due to hypertension]:

IV or STAT anti-hypertensive medications [includes oral Clonidine]: _____________________________________________________________________

Based on your medical judgment, can you further clarify in the progress notes whether the severity of hypertension in this case represents any of the following:

Hypertensive Crisis Hypertensive Emergency Hypertensive Urgency only Benign Hypertension only Hypertension without further specification Another condition (please specify) Not applicable / None of the above


22

[Malnutrition - severity]

The medical record indicates that this patient has been diagnosed as having MALNUTRITION with the following findings documented:

Clinical Findings [include all those that apply]:

o BMI < 16 (include actual BMI)

o Weight < 70% of ideal body weight (IBW)

o Weight < 75% of usual body weight (UBW)

o Unintended weight loss of > 5% in one month, > 7.5% in 3 months, > 10% in 6 months, or > 20% in one year: “Recent weight loss of _______ pounds over _______ months”

o Decreased hand grip strength

o Albumin and/or Prealbumin (if significantly low and not explained by other circumstances)

o Muscle wasting/atrophy

o Cachexia

High risk circumstances: [Cancer, malabsorption, other severe chronic GI disorder, debilitated, not eating, lack of social support, nursing home, other severe end-stage disease specified, alcohol/drug abuse]

Nutrition Consult:

Nutritional Supplementation:

Based on your medical judgment, can you further clarify in the progress notes the

SEVERITY OF MALNUTRITION:

Mild

Moderate

Severe





23

[Malnutrition – not yet diagnosed]

The following information is documented in the medical record regarding this patient’s nutritional status: Clinical Findings:

Nutrition Consult:

Nutritional Supplementation:

Based on your medical judgment, can you further clarify in the progress notes which, if any,

of the following conditions (and the severity, if applicable) may be causing these findings:

Malnutrition Weight loss only Underweight only Nutritional deficiency (please specify) Another cause (please specify) Not applicable / None of the above



24

[Pathologic / Osteoporotic Compression Fracture]

[THIS QUERY NOT NEEDED FOR OSTEOPOROSIS IF IT IS DOCUMENTED ANYWHERE IN THE MEDICAL RECORD AND ONLY MINOR TRAUMA]

Dear Dr. ______________________________________________

Documentation in the medical record indicates that this patient has been diagnosed with VERTEBRAL COMPRESSION FRACTURE(S) [spontaneously or following minor trauma]

Other documentation in the medical record includes: [describe underlying cause like

neoplasm and any mets] [multiple other compression fractures, if any]

Imaging: [describe X-ray, CT, and/or MRI]

Medications: [for osteoporosis or neoplasm]

Osteopenia on _________ X-ray

Based on your medical judgment, can you further clarify in the progress notes the most likely underlying cause of the Compression Fracture(s)?


25

[Pancytopenia]

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having [all that apply]:

Anemia

Neutropenia or Leukopenia

Thrombocytopenia


Hemoglobin = ____ Gm/dl

Absolute Neutrophil Count (ANC) = ______

Platelets = _________

Other information [any pertinent]:

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following these findings suggest:

Pancytopenia, unspecified cause

Pancytopenia due to chemotherapy

Pancytopenia due to radiotherapy

Pancytopenia due to another drug




26

INSTRUCTIONS – COMPLEX PNEUMONIA QUERY

On the following query, include the following clinical findings and risk factors, as applicable, which support the query for a more complex type of pneumonia, such as staph, gram-negative, aspiration or other complex pneumonia. If the patient has specific clinical indicators for aspiration, it may be more effective to use the Aspiration Pneumonia query.

HCAP: The predominant organisms causing HCAP (>80%) are gram-negative and staph . Antibiotics given ought to be those active against these organisms (see the CDI Pocket Guide).

Note: Patients who are receiving only antibiotics such as Rocephin, Zithromax, Quinolones (Levaquin or Avelox), or Doxycycline are usually being treated for a simple pneumonia, and this query may not be appropriate. Levaquin and Avalox are sometimes used for aspiration pneumonia. Cipro is sometimes used for Pseudomonas. Sometimes the physician may not have recognized aspiration as the cause and is not using an antibiotic for aspiration.

Clinical Findings: RLL infiltrate (aspiration) Open wound or ulcer (staph) IV catheter (staph) Structural lung disease like bronchiectasis (usually Pseudomonas) Recent antibiotic treatment Recent hospitalization

Risk Factors: Immuno-suppressed state Alcoholism / Drug abuse Ventilator status ESRD (often staph) Chronic debilitation GERD/esophageal disorder (aspiration) G-tube (aspiration) COPD (usually gram negative) Cancer Chemotherapy Steroids

27

[Pneumonia, Healthcare Associated (HCAP)]

Based on the documentation in the medical record, this patient has been diagnosed withHCAP (Healthcare Associated Pneumonia) but without definitive culture confirmation.

Additional documentation in the medical record suggests a likely or probable organism(s)

causing pneumonia:

Antibiotics:

Other clinical information: _[include any clinical indicators suggesting or associated with

gram-negative and/or staph]

Based on your medical judgment, can you further clarify in the progress notes whether

HCAP in this case (for which these antibiotics are being given in these circumstances) is

suspected, most likely, possibly, probably related to one or more of the following:

Aspiration

MRSA

Other Staph

Gram negative

Pseudomonas

H. influenza

Pneumococcus

Another organism (please specify)



28

[Aspiration Pneumonia]

Based on the documentation in the medical record, this patient has been diagnosed with

PNEUMONIA.

The following information is also documented in the medical record which may indicate a more specific type or cause of pneumonia:

______________________________________________________________________

[Include the following as applicable, which support the query for aspiration pneumonia:

Clinical Findings: RLL Infiltrate, vomiting, difficulty swallowing, impaired gag reflex, altered level of consciousness, abnormal swallowing study (normal study does not rule-out aspiration).

Risk Factors: Nursing home status, history of stroke / neurodegenerative disorder (e.g. MS, ALS), debilitated state / bed-confined, altered level of consciousness, alcoholic / drug intoxication or abuse, NG-tube, esophageal disorder (e.g. cancer, obstruction, stricture, etc.) / GERD.

Antibiotic treatment: Clindamycin, Flagyl, Zosyn, Augmentin, Levaquin, Avelox]

Based on your medical judgment, can you further clarify in the progress notes the likely or suspected underlying cause, if any, of the pneumonia in this case?


29

1

[Pressure Ulcer]

Documentation in the medical record indicates that this patient has been identified to have and/or is being treated for PRESSURE ULCER(s) of the following sites:

Please clarify the location/sites and the present on admission status of the ulcer(s) in the progress notes.


30

[Respiratory Failure, Acute]


diagnosed as having______________________________________________________.

The following is also documented in the medical record: Respiratory symptoms: _________________________________________________

Respiratory Rate: ____________

pO2 = _____ [and/or SpO2 = ____] on room air

pCO2 = _____ with pH = _____

P/F Ratio = ________ [if reported on ABG]

Treatment: [O2 % or L/min; BiPAP; CPAP; Ventilator; bronchodilator]

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following this condition is intended to indicate:

Acute hypoxic respiratory failure

Acute hypercapnic respiratory failure

Acute on chronic respiratory failure

Chronic respiratory failure

Hypoxemia only without respiratory failure

Other



31

[Respiratory Failure, Chronic]


diagnosed as having ______________________________________________________.

The following is also documented in the medical record [mark all that apply]:

End-stage lung disease Severe COPD

Home oxygen therapy at ____L/min

Elevated pCO2 = __________ Elevated HCO3 = __________

Pulse ox (SpO2) = on ________ [O2 % or L/min on room air]

pO2 on ________ [O2 % or L/min on room air]

Other:_________________________________________________________

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following condition(s) is responsible for these findings:

Chronic respiratory failure Abnormal blood gases only Another condition (please specify) Not applicable / None of the above


32

[Schizophrenia]


diagnosed as having SCHIZOPHRENIA.


Based on your medical judgment, can you further clarify in the progress notes the nature of

this patient’s schizophrenia :

Acuity

Acute

Chronic

Remission status

In remission

Not in remission





33

[Sepsis]

Based on documentation in the medical record, this patient is being treated for:

_________________________________________________________________________

The following criteria are also documented in the medical record [include only those that apply]:

Temperature = WBC = Pulse = Respirations = Lactate = Hypotension: Hypoxemia; SpO2 = ____ % on _____ O2 Acute kidney injury Acute respiratory distress/failure Mental status change / encephalopathy

Based on your medical judgment, can you further clarify in the progress notes the cause, if any, of these systemic findings including:

Sepsis

Septicemia

A localized infection only (without sepsis/septicemia)

Non-infectious SIRS




34

[Syncope]

Documentation in the medical record indicates that this patient was admitted for or with SYNCOPE. Other documentation in the medical record includes:

___________________________________________________________________________

Based on your medical judgment, can you further clarify in the progress notes the most likely, possible, probable underlying cause, if any, of this symptom such as:

Cardiac arrhythmia Structural/valvular heart disease

Cardiovascular medication Cerebrovascular occlusion (partial or complete)

Anemia / GI bleeding Seizure Disorder

AV block Autonomic neuropathy

Dehydration

Hypoglycemia

Vaso-vagal / vaso-depressor




35

[TIA]

Documentation in the medical record indicates that this patient has been admittedwith or diagnosed as having TIA.

The following information is also documented in the medical record:

Duration of symptoms: __________________________________

Atrial fibrillation

Abnormal Heart Valve(s)

Recent MI

Carotid Doppler showing:

Echocardiogram showing:

MRI or MRA showing:

Treatment with ASA Aggrenox Persantin Plavix Coumadin

Other: ______________________________________________________________

Based on your medical judgment, can you further clarify in the progress notes the possible, probable, likely, suspected underlying cause, if any, of the TIA symptoms such as:

Stroke / CVA

Transient cerebral thrombosis (without CVA)

Transient cerebral embolism (without CVA)

Occlusion or stenosis of a precerebral/cerebral artery (partial or complete) – please specify suspected artery

Another cause (please specify)



36

[Urosepsis]

Based on the documentation in the medical record, this patient is being treated for or diagnosed with UROSEPSIS. Urosepsis is no longer a codeable diagnosis and we need help with clarification of the intended meaning.

Based on your medical judgment, can you please further clarify in the progress notes whether this term is intended to indicate:

UTI ONLY

SEPSIS DUE TO UTI


37

[Probable/suspected cause of symptoms]


Based on your medical judgment, can you further clarify in the progress notes the most

LIKELY, PROBABLE OR SUSPECTED CAUSE OF THIS CONDITION


Please note that your response may include: Not applicable or none.

38

[Specific Diagnostic Condition]


Based on your medical judgment, can you further clarify in your progress notes a

SPECIFIC DIAGNOSTIC CONDITION associated with or causing the above findings or

symptoms?


Please note that your response may include: None or not applicable.

39

Clarification of Conflicting Diagnoses

We need your assistance resolving some conflicting information in the medical record.

Dr. ____________________ documented the following diagnosis in his/her note on [Date]:

Dr. ____________________ documented the following diagnosis in his/her note on [Date]

Other documentation in the medical record also indicates: [information that supports the

diagnosis and/or causes conflict]:

Based on your medical judgment, please clarify in the progress notes which, in your opinion,

is the correct diagnosis in this case.

Please note that your response may include: None of the above (please explain) or another

diagnosis (please specify).



40

Confirmation of a Diagnosis

The following diagnosis is documented in the record only once:

Other supporting information documented in the medical record includes:

Based on your medical judgment, please clarify in the progress notes whether or not

this patient actually has this diagnosis or, if not, another diagnosis (please specify)?

Please note that your response may include: Neither the documented diagnosis nor another

one.



41

Clinical Validation

Your assistance with confirmation of a documented diagnosis is requested because we cannot

identify adequate information in the medical record to support code assignment in this case.

Diagnosis: ______________________________________________________

Would you please clarify in the patient medical record whether:

1. This diagnosis is not confirmed and/or it has been ruled out.

2. This diagnosis is confirmed (please add additional supporting information to the

medical record)

42

[General Query Template]


Based on your medical judgment, can you further clarify the following in the progress notes:

Responses may include: Other (please specify) / Not applicable / None of the above



43

topic - pinson & tang€¦ · web viewmetabolic encephalopathy. toxic encephalopathy....

Documents