While most surgeons document the surgical procedures they perform in your facility with the utmost precision, there may be times when your coder needs clarification or additional documentation from the surgeon before she can assign the proper codes. When there's conflicting, incomplete or ambiguous information in the operative report, you must ask the physician to verify the procedure performed and get any written clarification in the form of an addendum. The official name for this is a "physician query." What it really means is, "Doc, we need you to clarify exactly what you did."

Don't lead physicians
Coders don't want to query a physician any more than the physician wants to receive a query, but when the surgeon's documentation leaves more questions than answers, you risk overcoding or undercoding if you don't ask for clarification. Here are some tips on handling physician queries.

• Formulate queries from the clinical documentation that the physician provided in the patient chart.
• Questions that appear to show preference for a particular response are not acceptable.
• Don't try to lead a physician to respond the way you'd like him to simply to increase reimbursement. A coder's role is to translate the physician's documentation, not dictate for him. Queries that appear to lead the provider to document a particular response could result in allegations of inappropriate upcoding.

The query format shouldn't sound presumptive, directing or as though the physician is being led toward a certain response, as in this example:

Based on the operative report, this Medicare patient had an open rotator cuff tear repair. There is a discrepancy between the "pre-operative diagnosis" and the "post-operative diagnosis" and the "indications" section of the operative report for this account. Please indicate "chronic tear," since reimbursement for this diagnosis is greater than that for an "acute rotator cuff tear."

The intent of this query is to lead the physician to provide an addendum or response based on reimbursement impact. This is unacceptable. Your coders should follow your facility's policies related to documentation, querying and coding while ensuring that ethical and legal coding practices are maintained.

A better alternative You may use the multiple-choice format in your queries as long as you list all clinically reasonable choices, regardless of the impact on reimbursement. The multiple-choice format should include an "other" option, with a line that lets the provider document additional comments. You should also give providers the choice of "unable to determine." This format is designed to make multiple-choice questions as open-ended as possible. Here's a look at an acceptable excerpt from a physician query:

Based on the operative report, this patient had an open rotator cuff tear repair. There is a discrepancy between the "pre-operative diagnosis" and the "post-operative diagnosis," which state "acute rotator cuff tear," and the "indications" section of the operative report, which states "This patient sustained a tear of his rotator cuff about 1 year ago. Conservative methods have failed and now he presents for an open rotator cuff repair in hopes of alleviating his ongoing chronic pain." Please confirm the patient's condition/diagnosis.

• Acute rotator cuff tear
• Chronic rotator cuff tear
• Unable to determine
• Other (please specify) __________

Physician education
To show physicians how they can improve their documentation, take an acceptable and an unacceptable operative report of theirs and show them the financial impact when specific information wasn't documented, versus when the additional information was provided after a physician query. With detailed operative documentation, code selection isn't a challenge. When accurate code selection is based on the most specific clinical documentation, you ensure your facility the maximum appropriate reimbursement for services rendered.