PHYSICIAN DOCUMENTATION QUERY FORM

Date:

Physician:

Coder:

Coder phone number:

Medical Record Number:

Patient Name:
Date of Service:
Dear Dr.

Please review the documentation in this patient's medical record so to ensure coding
accuracy and compliance. Please complete, sign and date the following documentation
query.
The following information in this patients record is unclear:
(State the specific information requiring clarification, if warranted the physician should
select his response from the checklist)
(add clinical indicators)

Other __________________
Unable to determine
Please respond to this query in the space below:

Physician Signature

Date

*Please return this completed query form no later than three weeks after receipt. This
completed query will be added to this patient's medical record.

References:
Schraffenberger, L. A., & Kuehn, L. (2011). Effective management of coding
services: The clinical coding managers handbook (4th ed). Chicago, IL: AHIMA
Publications.
Von Kirchoff, S. (2009). Coding and reimbursement for hospital outpatient services. (2nd
ed.). Chicago, IL: AHIMA Publications.
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?
dDocName=bok1_050018
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_040394.hcsp?
dDocName=bok1_040394