How to Write Effective Queries for Physicians

In the world of medical coding and clinical documentation improvement (CDI), clear and accurate physician documentation is vital. When documentation lacks specificity or detail, coders and CDI specialists often need to issue queries—formal requests for clarification or additional information from the physician. Writing effective queries helps ensure that the health record accurately reflects the patient’s condition, which is essential for proper coding, billing, compliance, and patient care.

Here’s a guide to understanding, crafting, and delivering physician queries that are professional, compliant, and effective.

What Is a Physician Query?

A physician query is a communication tool used by coders, CDI specialists, or billing staff to seek clarification or obtain missing documentation from a provider. Queries are typically issued when:

The documentation is conflicting, vague, or incomplete.

A diagnosis appears to be present but is not documented.

Clinical indicators suggest a condition that has not been explicitly stated.

Effective queries support accurate code assignment, improve quality metrics, and reduce audit risks.

Principles of an Effective Query

1. Clarity and Specificity

An effective query should be clear, concise, and to the point. Avoid medical jargon or overly complex language. Ask a direct question that guides the physician toward providing the necessary clarification without leading them.

Example:

“Can you clarify the type of heart failure (e.g., systolic, diastolic, or combined) for the patient admitted on July 20, based on the clinical findings of shortness of breath, reduced ejection fraction, and pulmonary congestion?”

2. Non-Leading and Objective

Queries must be non-leading, meaning they should not suggest a specific answer. Instead, they should present clinical facts and offer multiple, equally likely options—along with an “Other” or “Unable to determine” option.

Avoid:

“Was the patient’s anemia due to chronic kidney disease?”

Better:

“Based on the patient’s hemoglobin level and history of chronic kidney disease, can you clarify the type or cause of anemia, if any?”

3. Include Supporting Clinical Evidence

Cite the specific clinical indicators from the record that prompted the query. Reference lab results, imaging, physician notes, or progress reports that support the need for clarification.

Formats of Physician Queries

Verbal: Often used in real-time settings but should be documented.

Written (Paper or Electronic): The most common format, often part of EHR workflows.

Multiple Choice: Provide a list of clinically valid diagnoses or conditions.

Yes/No Queries: Use only when clarifying existing, documented diagnoses.

All queries must comply with AHIMA and ACDIS guidelines to avoid legal or compliance issues.

Best Practices for Success

Be respectful and collaborative—physicians are more likely to respond positively to professional, courteous communication.

Educate providers on why queries are issued and how they affect coding and quality metrics.

Follow institutional policies regarding timelines, documentation, and audit trails.

Track responses to identify trends or gaps in documentation that need systemic improvement.

Conclusion

Writing effective physician queries is both an art and a science. It requires understanding clinical language, knowing coding guidelines, and communicating clearly and compliantly. When done right, physician queries not only help capture accurate codes but also improve the quality of care documentation—benefiting providers, payers, and patients alike.

Learn : Medical Coding Training Course

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