Physician Query- Blank Template

In PDPM, your Non-Therapy Ancillary (NTA) score can significantly impact your facility's reimbursement, and every qualifying NTA diagnosis must be actively supported by physician documentation in the medical record. Without it, your MDS coding is exposed. The MD Physician Query Template by Insight MDS & Therapy Solutions gives your MDS coordinators and clinical team a clean, professional, and easy-to-use tool to query the resident's physician or nurse practitioner for diagnosis clarification and documentation support at the time of admission or readmission.

Why this tool matters:
NTA diagnoses carry significant per diem weight under PDPM. Conditions such as IV medications, infections, respiratory diagnoses, diabetes, and many others can add substantial NTA points, but only when the physician has actively documented the diagnosis as it relates to the resident's current clinical status, within 60 days of the ARD. When that documentation is missing, vague, or only referenced from a hospital discharge note, your facility risks coding inaccuracies, audit exposure, and lost reimbursement that cannot be recovered after the ARD is set.

How it works:
This simple, fillable one-page query form allows your MDS or nursing team to:

✅ Identify the diagnosis under consideration and its ICD-10 code(s)
✅ Document the supporting clinical rationale from the medical record
✅ Send directly to the treating physician or nurse practitioner for review
✅ Obtain a clear yes or no physician response with signature and date
✅ File the completed query directly into the resident's medical record as supporting documentation

What makes this tool valuable:
The MD Physician Query creates a clear, dated, and signed paper trail linking the physician's clinical judgment to the diagnosed condition, exactly the kind of documentation that supports your MDS coding, satisfies auditor review, and demonstrates that every coded NTA diagnosis was actively considered and confirmed by the treating provider during the look-back period.

Whether your team is working to capture a complex comorbidity, clarify an active versus resolved diagnosis, or ensure an NTA condition is properly tied to the resident's current plan of care, this query tool gives you a professional, compliant, and efficient way to get the documentation your MDS needs, without delays or guesswork.

This Template is a clinical documentation support tool only. Final diagnosis and coding decisions remain the responsibility of the treating physician and qualified MDS assessor.

📌 Licensed for use by one facility only. Not for redistribution or resale. Full Terms & Conditions provided upon purchase.