There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by

Question

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Using physician query forms is the most appropriate way to communicate with physicians for answers regarding incomplete or insufficient documentation. This method is formal, documented, and promotes adherence to coding and billing standards. Emailing, leaving notes in the chart, or calling the physician's office may be less effective, may not be appropriately documented, or may lead to misunderstandings or inconsistent practices.

There Are Times When Documentation Is Incomplete or Insufficient to Support