This page addresses follow-up questions and additional information pertinent to our webinar
The What, When, Who, and How of Physician Coding Queries.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q:  Do queries have to be multiple choice or are there other formats that are recognized? Are verbal queries acceptable?
A:  Written queries can also be open-ended to allow the provider to add free text responses, but we recommend using either a multiple choice or yes/no/unknown format since open-ended queries don’t always answer the question we’ve asked. There is more information about that in the Practice Brief. Verbal queries are acceptable, but all conversations should be documented. Conversations should be non-leading and include all appropriate clinical indicators and potential options.

Q:  For an infant born with a congenital anomaly, such as craniosynostosis, who has a family member who was born with the same condition, should code Z82.79, Family history of other congenital malformations, deformations, and chromosomal abnormalities, also be reported?
A:  Code Z82.79, Family history of other congenital malformations, deformations, and chromosomal abnormalities, is an optional code that may be reported in addition to codes for chromosomal anomalies on the baby’s record. If genetic testing is performed, this code should be added to help establish medical necessity.

Q:  Can you create a facility policy stating that acute blood loss anemia will not be coded or queried under certain circumstances?
A:  Yes. Some facilities have developed internal policies along with their clinical staff stating that acute blood loss anemia is an expected postoperative outcome and that the condition will not be coded or queried unless specific criteria are met.

Q:  Can you code from the anesthesia record on an inpatient encounter when the anesthesiologist documents a condition that impacts the ASA score?
A:  In general, we do not recommend coding from the anesthesia record on an inpatient encounter when the condition is not documented elsewhere. Although coding guidelines state that “the entire record should be reviewed to determine the specific reason for the encounter and the conditions treated,” anesthesia records do not always indicate which conditions specifically affected the ASA score. If there is a chronic condition that the anesthesiologist indicates affects the ASA score, in certain situations, it may be reportable, however, it is advisable that the condition be addressed elsewhere in the medical record by an attending or consulting provider. If there is a question on whether a condition affected an inpatient stay, the provider should be queried for clarification if there are clinical indicators to support the query. It is not advisable to create a “one size fits all” policy regarding coding from the anesthesia report, as the context of the documented condition should be considered.

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