Topic: AHIMA releases new query practice brief for comment
HIM Connection, June 3, 2008
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The American Health Information Management Association (AHIMA) on May 14 issued a practice brief entitled “Queries as a tool for clinical documentation improvement,” which updates the association’s existing physician query practice guidelines from 2001. AHIMA posted the document on its Web site, available to AHIMA members only, and allowed comments on the brief through June 2. AHIMA plans to publish its final brief in the September and October issues of the Journal of AHIMA.
The following is from the brief and describes AHIMA’s proposed requirements for a compliant query:
The query shall be written with precise language, identifying the clinical indicators (facts) from the medical record, and asking the physician to make a clinical interpretation of these facts based on the provider’s independent professional judgment of the case. Regulations are clear that the query cannot be posed in a leading manner, suggesting the answer to the provider. Query format should not sound presumptive, directing, prodding, probing, or as though the physician is being led to make an assumption. Query forms may not be designed to ask questions about a diagnosis or procedure that can be responded to in a yes/no fashion except for present on admission queries when the diagnosis has already been documented. Query forms shall not have the name of the condition, diagnosis or procedure listed on the form unless this condition, diagnosis, or procedure is already documented in the medical record and further specificity is being sought.
Multiple choice formats can be used so long as the physician has free choice to respond. For example, list all possible choices regardless of whether or not the choice impacts reimbursement or quality reporting. The choices should also include “other” with a line for the physician to add free text as well as “unable to determine.” This format is designed to make multiple choice questions as open ended as possible. Queries should be written in the form of a question directed to the provider to elicit a response for one condition at a time.
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