Health Information Management

Q&A: Leading multiple-choice queries

CDI Strategies, April 7, 2016

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Q: We are currently using a hybrid medical record, so we have standard query forms with multiple choice answer options that cannot be modified at this time. We are moving into an electronic medical record, where our queries could be more easily modified. Our compliance office has a concern with the CDI nurses removing some of the options that may not apply, because they feel it could result in the query being leading. We wanted to include this statement, "The list of diagnoses represent common conditions and may not be patient specific. Please check only those diagnoses/conditions that apply to the patient." Is our approach to the multiple choice query format appropriate?

 
A: The ACDIS/AHIMA position paper, Guidelines for Achieving a Compliant Query Practice, tells us we should not offer choices within a query that are not appropriate to the patient’s presentation and are not supported by clinical indicators. It is considered leading to offer choices that are not supported within the record. For this reason, best practice should allow CDI specialists to edit query templates and remove any choices that are not appropriate.
 
We should only provide choices that are supported by clinical indicators within the patient record, and then follow with choices such as unable to determine, other, not clinically significant, etc.
 
Often, I find people like to add statements, like the one you provided above, thinking this will lead to a more compliant process. But, if you are still offering a choice that is not supported by clinical indicators, then your query is not compliant regardless of whether or not you include your statement. If at the present time your queries cannot be modified, I would suggest you at least cross out those items that should not be included.
 
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.
 



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