HI253 Unit 7 Physician Query Letter Example

Course	HI253 Medical Coding I
Unit	Unit 7
Paper type	Physician query letter
Length	About 620 words, 5 pages double-spaced
Format	APA 7 student paper
School	Purdue University Global
Program	BS in Health Information Management
Updated	October 2026

Free sample paper for HI253 Unit 7

Hemoglobin From 12.6 to 7.8 and a Transfusion Without a Diagnosis: A Unit 7 Physician Query Letter Asking the Attending Surgeon to Clarify the Record Without Leading, With a Compliance Check Against the Query Practice Guidelines

[Student Name]

Purdue University Global

HI253: Medical Coding I

Unit 7 Physician Query Letter

[Instructor Name]

[Date]

The patient, the operation and every value are composite; the query practice standards and the sources cited are real.

What this part is doingThe letter opens by saying why the record needs clarifying, in clinical terms, so the surgeon reads it as a documentation question and not as a request for a particular answer.

The Query

To: Attending orthopedic surgeon, [Attending Name] From: Clinical documentation specialist, Health Information Management Patient: [Patient Name], [Medical Record Number] Encounter: inpatient admission, [Admission Date] to [Discharge Date] Query date: [Query Date] Clarification is requested so that the health record accurately reflects this patient's condition during the stay. Please review the clinical information below and document your clinical judgment in the progress notes or discharge summary. Clinical indicators:

1. Preoperative hemoglobin 12.6 g/dL, drawn at the preadmission visit.

2. Right total hip arthroplasty performed on hospital day 1; the operative note records estimated blood loss of 900 mL.

3. Postoperative day 1 hemoglobin 9.4 g/dL.

4. Postoperative day 2 hemoglobin 7.8 g/dL; nursing notes record lightheadedness on standing and a heart rate of 112.

5. Order on postoperative day 2 for two units of packed red blood cells; the progress note that day reads "Hgb 7.8, symptomatic, transfuse 2 units."

6. Postoperative day 3 hemoglobin 9.6 g/dL after transfusion.

Question: Based on your clinical judgment, can the condition being evaluated and treated with the transfusion on postoperative day 2 be further specified? Please select one and document it in the record:

1. Acute blood loss anemia

2. Expected postoperative decrease in hemoglobin, not clinically significant

3. Other (please specify): ____________________

4. Clinically undetermined

Provider signature: ____________________ Date: __________ The question asks what the surgeon was treating. It does not ask the surgeon to agree with anything.

What this part is doingOffering an expected-drop option beside the anemia option is what keeps the multiple-choice format from steering the surgeon toward one answer.

Compliance Check

1. Clinical indicators. Every indicator is drawn from the record and dated, and each one is something the surgeon can verify in the chart. Practice guidance for queries requires that a query present the clinical indicators that support the question rather than ask the provider to document a condition on the coder's word (American Health Information Management Association & Association of Clinical Documentation Integrity Specialists, 2022).

2. No leading. The options include more than one clinically reasonable answer, along with other and clinically undetermined. A query that offered acute blood loss anemia alone, or that listed only the indicators favoring it, would lead.

3. No codes and no money. The letter names no code, no grouping and no effect on payment, and it does not say what any answer would mean for the hospital.

4. The right recipient. The query goes to the attending surgeon, the provider responsible for the patient's diagnoses, because a transfusion order and the progress note behind it are the surgeon's own.

5. Why a query is needed at all. Coders may not assign a diagnosis from abnormal laboratory values or from the fact of a treatment; the provider must document the condition and its clinical significance (National Center for Health Statistics, 2025).

What this part is doingThe compliance check ties each feature of the letter to a named standard, which is how instructors usually grade this unit.

Why This Record Raised the Question

A fall in hemoglobin after hip replacement is common, and not every fall is a diagnosis. A systematic review of hip and knee surgery found that postoperative anemia affected about half of joint replacement patients and was associated with more transfusion, slower recovery and longer stays (Spahn, 2010). That is exactly why the record has to say which situation this was. A hemoglobin of 7.8 with symptoms and a transfusion is clinically different from an expected dilutional drop, but the coder cannot make that distinction, and the surgeon can.

References

American Health Information Management Association & Association of Clinical Documentation Integrity Specialists. (2022). Guidelines for achieving a compliant query practice (2022 update). American Health Information Management Association.

National Center for Health Statistics. (2025). ICD-10-CM official guidelines for coding and reporting FY 2026. Centers for Disease Control and Prevention.

Spahn, D. R. (2010). Anemia and patient blood management in hip and knee surgery: A systematic review of the literature. Anesthesiology, 113(2), 482-495. https://doi.org/10.1097/ALN.0b013e3181e08e97

HI253 Unit 7 instructions, in plain terms

Unit 7 commonly supplies a record excerpt with a gap or conflict in the documentation and asks you to write the query a coder would send. You are expected to address the right provider, present the clinical indicators with dates and sources, ask a question that does not lead, and offer options that include alternatives and an undetermined choice when you use a multiple-choice format. Most prompts mention the AHIMA and ACDIS practice brief by name and expect you to show how the letter meets it. Some ask for a separate paragraph explaining why the query was needed and what codes might be affected, kept apart from the letter itself. The length is usually one to two pages. Professional tone, a clear subject line and no reference to reimbursement are basic expectations.

How this HI253 Unit 7 example is built

The sample begins with the letter as it would be sent, addressed to the attending surgeon with a patient identifier and date of service. The indicators come first in a dated list: the hemoglobin values, the transfusion order and the estimated blood loss from the operative report. A highlighted line states that the question asks what the surgeon was treating and does not ask for agreement. The options follow, with an expected loss choice placed beside a diagnosis so neither looks preferred. The compliance check then reviews the letter point by point against the practice guidelines, covering tone, options, absence of financial impact and retention in the record. A last section explains, outside the letter, why the transfusion raised a documentation question in the first place and cites research on blood management after joint surgery.

Where the points sit in the HI253 Unit 7 rubric

Graders usually split the points between the letter and the reasoning around it. Inside the letter, the heaviest weight falls on clinical indicators that are specific, dated and sourced, and on a question phrased so it does not suggest the answer. Options are checked for balance: a query that offers only one diagnosis, or omits other and undetermined, tends to lose a large share. Mentioning reimbursement or a code inside the letter usually costs points outright. Outside the letter, the compliance review earns credit when it ties each feature to the practice guidelines rather than restating them. Professional tone, correct recipient and an APA reference list complete the rubric. A query that reads as neutral and complete when read aloud is the standard most instructors apply.

Common HI253 Unit 7 mistakes, and how to avoid them

Leading wording is the error that costs most, such as asking the surgeon to confirm acute blood loss anemia. Students also list indicators without dates or sources, which leaves the provider to search the chart. Some offer a single yes or no question about a diagnosis that has not been documented anywhere, which the guidelines treat as leading. Others mention that a different answer would raise the payment, which no compliant query may do. Sending the query to the wrong provider, or writing to the nurse who recorded the values, also loses points. We can draft a query letter for the record in your assignment, with a compliance review keyed to the current practice brief. Send the excerpt, the provider names given and any format your instructor wants followed.

Get an HI253 Unit 7 example written to your instructions

Include the case documentation your Unit 7 assignment gives you, identifiers removed, the query template if your section has one, and the rubric, and say which provider the scenario names. The letter comes back with indicators drawn from that record, options that do not steer, and a blank provider line, in 24-48h. A first custom sample is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.

More HI253 papers and BS in Health Information Management samples

HI253 Unit 7 questions, answered

Can a query include the diagnosis the coder thinks is right?

Only as one of several clinically reasonable options, and only when the indicators support it. A multiple-choice format with alternatives, other and clinically undetermined does not lead, while a query that presents one diagnosis alone does. The sample includes the anemia option beside an expected blood loss option for exactly that reason. Your instructor may use a specific template, and the rules still apply inside it.

Why is the query sent to the attending and not the anesthesiologist?

The sample addresses the provider responsible for the patient's diagnoses during the stay, which is typically the attending. Some scenarios involve a consultant or another provider who documented the relevant findings, and the query would go to them. What matters for grading is that the recipient can legitimately document a diagnosis and that the letter makes the choice of recipient clear.

Should a query be written or verbal?

Both are recognized in practice, but coursework nearly always wants the written form because it can be graded and retained. Verbal queries still need to be documented with the same content, indicators and options, so the discipline is identical. A Unit 7 letter that would sound neutral if read aloud to the provider usually meets the tone expected in writing too.

Where can I find a free HI253 Unit 7 sample paper?

A full Unit 7 physician query letter is on this page, about an unexplained transfusion after a hip replacement, with dated indicators, neutral options and a compliance check.

Can a coder mention payment in a physician query?

No. A compliant query presents clinical indicators and asks a clinical question. Any statement about reimbursement or quality scores makes the query leading under the AHIMA and ACDIS guidelines.