ICD-10-CM Query Template Example Dear Dr. XXXX, By submitting this query, we are merely seeking further clarification of documentation to accurately reflect all conditions that you are monitoring; evaluating, treating or that extend the hospitalization or utilize additional resources of care. Please utilize your independent clinical judgment when addressing the question(s) below. ***Add specific documentation from the medical record to describe the clinical picture: *** 1) Specify if fracture is open or closed 2) Specify the laterality (left, right or bilateral) 3) Specify the type: ComminutedSegmental ObliqueTransverse SpiralOther 4) Specify the cause: Traumatic (traumatic compression fracture or traumatic fracture) Non traumatic: Chronic fractureDue to Osteoporosis Non-traumatic compression fractureDue to malignancy Stress fracturePathological fracture Other Reimbursement can be impacted by the status of the fracture as opened or closed Code assignment varies by etiology of the fracture

Dear Dr. XXXX, By submitting this query, we are merely seeking further clarification of documentation to accurately reflect all conditions that you are monitoring, evaluating, treating or that extend the hospitalization or utilize additional resources of care. Please utilize your independent clinical judgment when addressing the question(s) below ***Add specific documentation from the medical record to describe the clinical picture: *** **Please clarify/provide Applicable Diagnosis for above information** 1) Please specify the Alcohol use as: Use Abuse Dependence Other Unable to determine 2) Specify if patient is having any alcohol withdrawal and/or delirium 3) If known please specify the Blood alcohol level (blow in lab value) ICD-10-CM Query Template Example Alcohol “withdrawal” can only be associated with a dependence level of abuse and the associated combination code adds a complicating conditions (CC)

ICD-10-CM Query Template Example Dear Dr. XXXX, \By submitting this query, we are merely seeking further clarification of documentation to reflect the severity of illness of your patient. Please utilize your independent clinical judgment when addressing the question(s) below. ***Add specific documentation from the medical record to describe the clinical picture: *** *Urosepsis has no code in ICD 10 * 1) Can the term "urosepsis“ be further clarified as one of the following diagnoses?  Simple "UTI"  Sepsis" secondary to a urinary source (i.e. UTI)  Other condition(please specify): _______________  Unable to determine Please specify the causative organism associated with the infectious process (if known ) *NOTE: a different query would be necessary if the patient has an indwelling Foley catheter to clarify any potential relationship between the two Reimbursement varies based on UTI or sepsis

ICD-10-CM Query Template Example Dear Dr. XXX, By submitting this query, we are merely seeking further clarification of documentation to accurately reflect all conditions that you are monitoring, evaluating, treating or that extend the hospitalization or utilize additional resources of care. Please utilize your independent clinical judgment when addressing the question(s) below. ***Add specific documentation from the medical record to describe the clinical picture: *** 1. Please document if the Burn is thermal ( from heat source) or corrosion ( from chemical source) 2. Please document the Burns to include: _____ Total TBSA (Total Body surface Area) _____ Percentage 3 rd degree (full thickness) _____ Percentage 2nd degree (partial thickness) _____ Percentage 1 st degree Documentation necessary for specificity rather than reimbursement could impact SOI/ROM

ICD-10-CM Query Template Example “Dear Dr. XXXX, By submitting this query, we are merely seeking further clarification of documentation to accurately reflect all conditions that you are monitoring; evaluating, treating or that extend the hospitalization or utilize additional resources of care. Please utilize your independent clinical judgment when addressing the question(s) below. ***Add specific documentation from the medical record to describe the clinical picture: *** **Please clarify/provide Applicable Diagnosis for above information** Acute Respiratory FailureChronic Respiratory Failure Acute and Chronic Respiratory Failure Acute respiratory Distress OtherUnable to determine **Please specify any exposure to tobacco smoke** Exposure to environmental tobacco smokeHistory of tobacco use Occupational exposure to environmental tobacco smokeTobacco dependence Tobacco use Specify the underlying cause of “Respiratory Failure or Respiratory Distress Following/due to surgeryFollowing /due to trauma Due to underlying respiratory disease (specify)Other Unable to determine Documentation of "Respiratory Insuffiencey/Distress" is not interchangable with "Respiratory Failure" Diagnosis of respiratory failure does not require that the patient have mechanical ventilation or other respiratory assistance. It is up to the provider to determine whether the patient has clinical signs indicating respiratory failure as an appropriate diagnosis. Please document any additional diagnosis and/or specificity in the progress note and/or d/c summary. Impacts reimbursement specificity Impacts code assignment but not necessarily reimbursement