A physician query is sometimes called a clarification, clinical clarification, or documentation clarification. What is another term used for a query?

A physician query is sometimes called a clarification, clinical clarification, or documentation clarification. What is another term used for a query?

• A. Documentation alert
• B. Clinical decision support
• C. Audit reminder
• D. Coding guidance

Answer: (A)

Documentation alert is the term used for a physician query in some workflows. A physician query asks the provider to add or specify documentation to support the coded diagnosis or procedure. In many documentation systems, the prompt that triggers this clarification is called a documentation alert, drawing attention to documentation gaps that affect coding. This differs from clinical decision support, which provides guidance to clinicians but isn’t a direct request for clarification in the medical record; an audit reminder is merely a reminder during an audit; coding guidance refers to rules for coding, not a direct request for physician input.

Documentation alert is the term used for a physician query in some workflows. A physician query asks the provider to add or specify documentation to support the coded diagnosis or procedure. In many documentation systems, the prompt that triggers this clarification is called a documentation alert, drawing attention to documentation gaps that affect coding. This differs from clinical decision support, which provides guidance to clinicians but isn’t a direct request for clarification in the medical record; an audit reminder is merely a reminder during an audit; coding guidance refers to rules for coding, not a direct request for physician input.