Health Information Management

Tip: Use AHIMA guidance as basis for CDI query processes

CDI Strategies, March 18, 2010

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Although AHIMA’s October 2008 practice brief “Managing an Effective Query Process” clearly states that the agency intended the article as guidance, not regulation, CDI programs should regularly review their query practices, policies, and procedures to determine if any problem areas may need to be addressed.
AHIMA lists the following examples as opportunities to query physicians:
Legibility: Defined as handwriting that cannot be read by two other individuals.
Completeness: Represented by an abnormal test result for which a clinical interpretation has not been given or the indication for a prescribed pharmaceutical was not provided.
Clarity: Represented by a patient with a symptom for which an underlying cause was not described (e.g., fever, abdominal pain).
Consistency: Represented by conflicting documentation by a treating provider (e.g., sepsis on one progress note, urosepsis on the discharge summary) or between two different providers (e.g., stroke documented by a neurologist, transient ischemic attack documented by the attending physician on the discharge summary).
Precision: Represented by the need for greater specificity of diagnoses when allowed for by ICD-9-CM. For example, fourth- and fifth-digit codes for congestive heart failure (CHF) characterize it as acute or chronic systolic or diastolic failure in ICD-9-CM.”
Essentially, the AHIMA brief says queries should be limited to conditions in which conflicting, ambiguous, or incomplete information regarding significant reportable conditions or procedures exist in the medical record. It further states that queries should not direct the physician to document a specific diagnosis, nor indicate any financial or quality reporting outcomes as a result of his or her response to the query.
Editor’s Note: Lynne Spryszak, RN, CCDS, CPC-A, and Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, coauthors of The Physician Queries Handbook, present the Tuesday, March 24 audioconference “The Physician Queries Workshop: Tools and Techniques for Compliant, Effective Clarification.” During the audioconference, participants will learn to:
  • Identify the elements of a compliant query
  • Demonstrate the ability to write an “audit-proof query”
  • Determine which documentation situations are appropriate for templates and which require a “customized” approach
  • Draft compliant, effective queries for common diagnosis clarifications

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