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Question: In a recent encounter, a provider documented that a patient had a patient-health questionnaire-9 (PHQ-9) score of 14, which usually indicates moderate major depressive disorder. The provider also documented the patient having more severe symptoms and adjusting their medication accordingly. However, the provider documented a diagnosis of mild recurrent major depressive disorder. If I query the provider to ask about this, would it be considered 鈥渓eading鈥�?

Kentucky Subscriber

Answer: It鈥檚 important to code from the provider鈥檚 documentation, specifically from their language, and seeking more clarification can be extremely important.

In this situation, you can word the query so it would not be leading. For example, you could query the provider noting that you observed some discrepancies in the documentation regarding the diagnosis and the severity of the condition.

If you write a query saying, 鈥淪houldn鈥檛 this patient be diagnosed with moderate major depressive disorder because their PHQ score is 14?鈥�, you鈥檙e more directly questioning the provider鈥檚 clinical judgement and seemingly angling for a specific answer.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC