This “In the kNOW” edition is going to cover the updated AHIMA-ACDIS practice brief on “Guidelines for Achieving a Compliant Query Practice (2022 Update)”. This practice brief was a collaborative effort between AHIMA and the Association of Clinical Documentation Integrity Specialists (ACDIS), and was released mid-December 2022.
The query process is a mechanism to clarify information within a health record to ensure documentation integrity and enable the accurate coding for diagnoses, procedures, and services. The focus of a query is a specific individual encounter regardless of the healthcare setting (inpatient/outpatient). Healthcare professionals, such as clinical documentation improvement specialists (CDIS) or coding professionals, may create queries or templates to be used.
Queries must be compliant. This includes being clear and concise, and including clinical indicators to support the query. Multiple choice queries are required to include the option for “Other” but there is no requirement on the number of options that must be provided or the order in which they must be listed. Additionally, multiple choice answers should not provide an option that is not supported by clinical indicators. However, a new diagnosis may be introduced in a multiple choice query if clinical indicators support the diagnosis.
Be careful using “Unable to determine” as an option for multiple choice as it is not the same as possible or unable to rule out. “Unable to determine” does not qualify as an uncertain diagnosis. Do note, that “Unable to determine” must be provided as an option in Yes/No or POA queries. The query should not contain any information as to the impact responses will have on the reporting of quality or regarding reimbursement.
Be mindful that the titles of queries should not be leading with the same being true of the query statement. When templates are being used, they must be able to be edited to remove options that are not clinically relevant.
Information from prior encounters may be used to support a query in certain circumstances. For example, when trying to obtain specificity for conditions such the stage of CKD or type of heart failure. Prior encounter information can also be used to determine POA status, determine cause-and-effect relationship, or determine etiology of a condition or prior patient baseline. It may be necessary to use prior encounter information to determine “history” of a condition or when treatment or monitoring of a condition from a previous encounter is currently referenced.
Clinical indicators may be taken from any of the documentation in the patient’s record. This would include EMS, provider documentation (H&P, progress notes, consults, diagnostic findings, op reports), ancillary service documentation (nursing, case management, respiratory therapy, speech therapy, etc.).
Queries should be addressed to the provider who provided the care. The exception to this is when there is conflicting documentation between providers, and then the query should be directed to the attending provider. Queries may also be directed to other clinicians that are not classified as providers. This could include nurses, dietitians, respiratory therapists, or case managers.
Query formats include open-ended, yes/no, and multiple choice. It is important to utilize Yes/No queries only for clarification of diagnoses where specificity is needed. This includes determining POA status, substantiating clinical findings, or determining a cause-and-effect relationship.
Escalation policies should be in place for queries that go unanswered. Expectations for everyone involved in the query process should be outlined with the inclusion of the time frames for completion. Identification of the appropriate individual(s) to follow up on outstanding queries should be covered as well.
Additional detail on compliant query practices can be found in the updated practice brief. I urge you to download and read the brief and then compare your facility’s practices with the guidance provided. It may be time to update your internal practices based on this new query update.
Now you are In the kNOW!!
Dianna Foley, RHIA, CCS, CHPS, CDIP is
OHIMA's Education Coordinator. Dianna has been an HIM
professional for over 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She previously served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati and holds RHIA, CHPS, CDIP and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and is a presenter on coding topics at the national, state, and regional levels. Dianna mentors new AHIMA members and also provides monthly educational lectures to coders and clinical documentation specialists.
