Q&A: Members of ACDIS advisory board offer advice on queries

Lynne Spryszak, RN: If it appears that resources are being used, or if I see an obvious overlooked abnormal test that may indicate a secondary condition, I will write a query referring the physician to the attached lab/test result asking if the findings represent (fill in the blank) and if so to please add this condition to their next note.

I just had one recently for a gross U/A result (packed bacteria, full fields of RBCs and WBCs, positive nitrites) and I asked the physician about it. He came up after I'd written the query and he said he didn't know how the ER had missed it or missed ordering a urine C/S.

I often use the Uniform Hospital Discharge Data Set (UHDDS) guideline for a reportable condition, which are “Conditions that affected patient care in terms of requiring:

Colleen Garry, RN, BS: I caution you in the wording "incidental findings.” It has a bias and it is in conflict with coding rules (a diagnosis has to have clinical significance in order for you to code it). I would not think that too many things are incidental. If the physician documented something as "incidental" you cannot code it.

As a clinician, I always base my queries and back them up with substantial clinical references. Always practice ethics with all queries and be ready to defend your reason for asking with supportive clinical data. I feel this is a safe practice. Also, don’t forget teamwork: The coding manager and your compliance department will need to collaborate with CDMP on your policy. Consistency of query practice is essential. I recommend auditing documentation specialists queries for content and verbiage.