Health Information Management

Q&A: Are query headings permissible?

CDI Strategies, January 31, 2013

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Q: I was under the impression that headings on a query form are leading.  Can you help me with this?  I would use a heading but replace the (example: Acute Renal Failure) with the physician’s wording (ex: Renal insufficiency).  Then paint the clinical picture with appropriate choices.

A: Not all query titles are leading; however existing physician query guidance cautions against using a query title that dictates the intended documentation. For example, you would not want to title a query template Acute Blood Loss Anemia Query as it could appear the provider is being influenced to document the diagnosis of acute blood loss anemia. 
 
A more appropriate title for the template would be Anemia Specificity Query and you should only use it when the provider has already documented anemia. Also, you aren't required to title your query templates, but if you do, make the title generic. 
 
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question which was originally published on the ACDIS Blog. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.



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