Physician Query Best Practices

When to query physicians, how to write effective queries, and templates for common scenarios

The Critical Role of Physician Queries

Physician queries are essential tools for IRF-PAI coordinators to obtain clarification and additional documentation when medical record information is incomplete, unclear, or conflicting. Proper querying ensures accurate coding, appropriate tier assignment, and compliance with CMS guidelines while maintaining the integrity of clinical documentation.

Why Physician Queries Matter:

  • • Ensure accurate comorbidity identification and tier assignment
  • • Clarify conflicting or ambiguous documentation
  • • Support appropriate reimbursement based on patient complexity
  • • Prevent MAC audit denials due to insufficient documentation
  • • Maintain compliance with CMS coding and documentation standards
When to Query Physicians
Specific scenarios requiring physician clarification

1. Unclear or Conflicting Documentation

Query when:

  • • H&P lists "CHF" but progress notes state "no cardiac issues"
  • • Medication list includes diabetes medications but no diabetes diagnosis documented
  • • Lab values suggest CKD but no kidney disease mentioned
  • • Conflicting information between different providers' notes

2. Incomplete Diagnosis Specificity

Query when:

  • • "Diabetes" documented but type not specified (Type 1 vs Type 2)
  • • "CHF" without specifying acute vs chronic, systolic vs diastolic
  • • "CKD" without stage specification (Stage 1-5)
  • • "Anemia" without underlying cause or type

3. Clinical Indicators Without Diagnosis

Query when:

  • • Patient on diuretics and daily weights but no CHF diagnosis
  • • Nebulizer treatments ordered but no COPD/asthma documented
  • • Insulin ordered but no diabetes diagnosis
  • • Phosphate binders ordered but no CKD documented

4. "History Of" vs Active Condition

Query when:

  • • "History of CHF" but patient on active CHF medications
  • • "History of COPD" but receiving respiratory treatments
  • • Unclear if condition is currently active or resolved
  • • Need clarification on current treatment status

5. Comorbidity Tier Impact

Query when:

  • • Patient appears to have 3+ comorbidities but only 2 clearly documented
  • • Need clarification to support Tier 2 or Tier 3 assignment
  • • High-impact condition suspected but not explicitly stated
  • • Comorbidity count at threshold (1-2 for Tier 2, 3+ for Tier 3)

6. Missing Comorbidity Documentation

Query when:

  • • Obvious clinical indicators present but no diagnosis
  • • Lab values abnormal but condition not addressed
  • • Medications suggest condition but not documented
  • • Specialist consults obtained but diagnosis not in problem list
How to Write Effective Physician Queries
Best practices for compliant query construction

Core Principles:

✓ DO:

  • • Be specific and objective
  • • Reference specific clinical indicators
  • • Provide multiple-choice options when appropriate
  • • Include "other" or "clinically undetermined" options
  • • Use neutral, non-leading language
  • • Document date and time of query

✗ DON'T:

  • • Lead the physician to a specific answer
  • • Suggest a diagnosis not supported by clinical evidence
  • • Query solely to increase reimbursement
  • • Use yes/no questions (use multiple choice)
  • • Query after discharge without clinical basis
  • • Pressure physicians for specific responses

Required Query Components:

1

Patient Identification

Name, MRN, admission date, primary diagnosis

2

Clinical Indicators

Specific findings, lab values, medications, or treatments that prompted the query

3

Specific Question

Clear, focused question about the clinical condition

4

Response Options

Multiple-choice options including "other" or "clinically undetermined"

5

Signature and Date

Space for physician signature, date, and time

Physician Query Templates
Ready-to-use templates for common query scenarios

Physician Query Best Practices

Timing:

  • • Query during IRF stay, not after discharge
  • • Submit queries promptly when issue identified
  • • Allow reasonable time for physician response
  • • Follow up if no response within 24-48 hours

Documentation:

  • • Keep copy of all queries in medical record
  • • Document physician response and date/time
  • • Track query rate and response rate
  • • Review queries during internal audits

Communication:

  • • Use respectful, professional language
  • • Educate physicians on query purpose
  • • Provide feedback on query outcomes
  • • Build collaborative relationships

Compliance:

  • • Never lead physicians to specific answers
  • • Ensure queries are clinically appropriate
  • • Avoid queries solely for reimbursement
  • • Follow AHIMA/ACDIS query guidelines
Common Query Mistakes to Avoid

❌ Leading Query:

"Patient has CHF, correct?"

✓ Better: "Based on furosemide use and elevated BNP, please clarify cardiac diagnosis."

❌ Yes/No Question:

"Does patient have diabetes?"

✓ Better: Provide multiple-choice options including "clinically undetermined."

❌ Vague Query:

"Please clarify medical history."

✓ Better: Reference specific clinical indicators and ask focused question.

❌ Post-Discharge Query:

Querying after patient discharged without concurrent clinical basis

✓ Better: Query during IRF stay when clinical indicators are present.