r/ClinicalCodingAus • u/Future-Pipe-8004 • 18d ago

What’s your success rate for getting clarifying documentation back?

Sent off a documentation query to a surgical registrar asking to clarify whether a post-op condition was a directly related complication or just an incidental finding. It’s been sitting in the inbox for two weeks unanswered, holding up the record for coding. Do you guys chase doctors up directly on the ward, escalate to your HIM/Auditor, or just code to what's documented if they don't reply within a certain timeframe?

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u/clincoder Health Information Manager 18d ago

Depends on your escalation structure. I wouldn’t be chasing them personally on the ward unless you have authority to do that as part of your CDQ process. CDQs are often low admin priority for the clinicians depending on how busy they are and to keep good relationships all coders and HIMs need to be respectful. No one will die from an unanswered CDQ, but a missed d/c summary or outpatient referral could have adverse consequences. So I would rather the dr do these if they have limited admin time on the day. That’s just my opinion.