Sample physician query form - Acumentra Health

SAMPLE PHYSICIAN QUERY FORM
Date:____________
Patient name ___________________________
Admit date __________________ Discharge date __________________
Medical record no. _____________________ Account no. _____________________
Coder name ______________________ Coder phone number ____________________
Dear Dr. ______________________:
The documentation in this patient’s record requires clarification to ensure coding
compliance and accuracy. Please complete, sign, date, and return the following query.
The following information is recorded in [state the specific location in the medical
record of information contributing to the reason for query.]
[List the information; for example,
“Sputum lab culture result verifying presence of {particular organism} in a
patient with a documentation of pneumonia”]
I have the following question about this record:
[Example:”Was the patient’s pneumonia caused by a specific organism?
If yes, please specify the organism.”]
Please respond to this question in the space below.
[allow space for written entry]
[If your policy requires, instruct the physician to make an addendum: “You must also
add this information to the patient’s medical record by an addendum to the progress
notes or discharge summary.”]
_____________________________
Physician signature
___________________
Date
Acumentra Health 503-279-0100 www.acumentra.org

PHYSICIAN QUERY AND MEDICAL RECORD ADDENDUM
Date:____________
Patient name ___________________________
Admit date __________________ Discharge date __________________
Medical record no. _____________________ Account no. _____________________
Coder name ______________________ Coder phone number ____________________
Dear Dr. ______________________:
The documentation in this patient’s record requires clarification to ensure coding
compliance and accuracy. Please complete, sign, date, and return the following
query, as it will become part of the patient’s medical record.
The following information is recorded in ______________________________.
I have the following question about this record:
Please respond to this question in the space below.
_____________________________
Physician signature
___________________
Date
Acumentra Health 503-279-0100 www.acumentra.org

PHYSICIAN QUERY
Date:____________
Patient name ___________________________
Admit date __________________ Discharge date __________________
Medical record no. _____________________ Account no. _____________________
Coder name ______________________ Coder phone number ____________________
Dear Dr. ______________________:
The documentation in this patient’s record requires clarification to ensure coding
compliance and accuracy. Please complete, sign, date, and return the following query.
The following information is recorded in ______________________________.
I have the following question about this record:
Please respond to this question in the space below.
Important: You must also add this information to the patient’s medical record
by a separate addendum to the progress notes or discharge summary.
_____________________________
Physician signature
___________________
Date
Acumentra Health 503-279-0100 www.acumentra.org

This material was prepared by Acumentra Health, Oregon’s Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
8SOW-OR-REV-07-06
10/10/07
Acumentra Health 503-279-0100 www.acumentra.org