Physician's Coding Strategist: CMS issues memo on use of physician query forms

The director of the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Group has issued a Policy Clarification Memorandum stating that "the use of the physician query form is permissible to the extent it provides clarification and is consistent with other medical record documentation."

This clarification reverses a similar memo issued in January 2001 instructing peer review organizations (PROs) not to accept physician query forms as a substitute for documentation in the medical record.

According to the new procedures for PRO reviewers in the Oct. 11 Policy Clarification: "In conducting medical review for validating the DRG, the PRO reviewer shall use his or her professional judgment and discretion in considering the information contained on a physician query form along with the rest of the medical record for purposes of DRG validation. If the physician query form is leading in nature or if it introduces new information, the reviewer shall refer the case to the physician for review. The PRO must perform physician review as described in the PRO Manual at 4130(D) and provide the opportunity for discussion if necessary."

When the Paperwork Reduction Act eliminated the need for physician attestation for Medicare inpatient cases in 1992, the physician query form lost popularity. However, its use has increased once again with the renewed emphasis on fraud and abuse issues.

Professional coding standards say coders should ask physicians for clarification and additional documentation before they code a case file containing conflicting or ambiguous data. The Office of Inspector General’s Compliance Guidance for Third-Party Billing Companies also notes that coders should communicate with physicians when their documentation is unclear or conflicting.