The Diagnosis Query Process

The querying of the provider for clarification of a diagnosis in order to assign the most specific code can be a tricky proposition.  This session will cover the parameters for obtaining this information from the provider without being in conflict with the oversight and compliance process of the ICD-10-CM coding oversight and compliance.  The way and manner of requesting for clarification determines whether the request is interpreted as leading to a specific, desired diagnosis.   The structure of a compliant query will be discussed and sample compliant tools reviewed.

DISCLOSURES

None of the planners or presenters for this activity have relevant financial relationship(s) to disclose with ineligible companies.

About the speaker:

Mary Ann P. Leonard, RHIA, RAC-CT owner and operator of Health Information Professionals, LLC, a health information management consulting company. Health Information Professionals holds contracts for HIM consulting services with over 100 facilities in Pennsylvania, Delaware and Maryland. A graduate of Temple University’s Health Information Management program, Mary Ann has worked as a Medical Records Consultant in long term care for over 3 decades. She has conducted educational programs on various medical records related topics and conducts the medical record portion of the Nursing Home Administration program for several NHA programs in Pennsylvania. She has presented on a number of HIM related topics for the Pennsylvania Health Information Management Association, the New Jersey Health Information Management Association, the Long Term Care Spring Conference sponsored by the American Health Information Management Association and various other professional associations. Mary Ann is also active in the Pennsylvania Health Information Management Association and the American Health Information Management Association by holding various positions and membership in the Long Term Care Practice/Continuity of Care Council. She is an AHIMA Approved ICD-10-CM trainer. She is a founding and charter member of the Pennsylvania Association of Nurse Assessment Coordinators.