Note from the ACDIS Interim Director: The new query practice brief is open for review

by Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC

I am a rule follower. I was raised that way by my father. He taught me rules were made to be followed, and if the rules don’t make sense, work to change them. With that thought in mind, I have loved the work that ACDIS and AHIMA have done to co-author  and maintain the Guidelines for Achieving Compliant Query Practice©*. With each update and revision over the years, we’ve recognized that query practices have changed. The understanding that more individual job roles engage in physician queries, that queries are applied in numerous healthcare settings, and that queries are deployed for more varied purposes than ever before, has allowed us to evolve and apply these communication tools in a number of diverse ways.

Many of you remember the days when queries could only be written in open-ended format, or when we could not source clinical indicators from previous encounters, or when yes/no queries could only be used to clarify present on admission (POA) status. With each revision over the years, the Guidelines for Achieving a Compliant Query Practice© has worked to recognize the evolving landscape of coding and CDI practice. That said, the main message of this document has remained constant: our query communications must be compliant, meaning it must not lead or pressure the provider to document in a desired fashion. The goal of our query clarifications is to obtain strong, complete documentation that allows for accurate code assignment and claims data.

This last revision, newly released for public review and comment, was thoughtfully written by a committed group of professionals working to maintain compliance in query practice. Our goal was to further clarify the guidance, especially in areas where perhaps it has been misinterpreted in the past, to clearly define compliance in query practice, and to provide a tool for organizations to define, educate, and evaluate query practices within their purview. I encourage you to review the brief and offer your comments during this period of public review open through Tuesday, October 25.

We recognized there were many stakeholders in the process of query, and so want to include other healthcare professionals such as quality, compliance, revenue cycle, patient financial services, physician groups, facility leaders, and care management, as well as external auditors, payers, and compliance agencies in this review. We all must seek common ground in what is compliant query practice so that we may work together in accomplishing the same goal of complete and accurate documentation. Our hope in this revision is to provide that consistency, with rules that are clear, easy to follow, and applicable in every situation a query may be deployed.

Defining a query

The definition of query has evolved a bit over the years. Significant changes made include the ability to utilize verbal queries, the addition of prospective queries in the outpatient setting, and the application of technology to the process. This latest practice brief offers the following definition of query:

”A communication tool or process used to clarify documentation in the health record for documentation integrity and accuracy of diagnosis/procedure/service code(s) assignment for an individual encounter in any healthcare setting. A query may be developed by a healthcare professional or through a computer or autogenerated query process.”

Support for the premise of the query is the core contributor to compliance. Applicable clinical indicator(s) must be identified and included. This updated brief stresses the importance of clinical indicator(s) with an identified section speaking to the presence of clinical support, where they can be sourced and how they should be used.

Clinical indicator(s) are defined broadly to “encompass documentation that supports a diagnosis as reportable and/or established the presence of a condition.” Clinical indicators should be clear, concise, and directly related to the current encounter, although they may be sourced from prior encounters as appropriate. The writers of this brief strongly wished to identify that “there is no required number of clinical indicator(s) that must accompany a query because what is a ‘relevant’ clinical indicator will vary by the diagnosis, patient, and clinical scenario.”

Query formats

The past direction related to verbal query remains. Notation of the date, reason (to include clinical indicators), and provider response must be recorded and maintained per organizational policy.

Written queries can be formatted as open-ended, multiple choice, and yes/no formats. Yes/no formats can only be used to determine POA status, substantiate a diagnosis already present in the current record, resolve conflicting documentation, or clarify a cause-and-effect relationship between two conditions.

The co-authors also wished to clarify the compliant use of multiple choice queries, stressing that there is no mandatory or minimum number of choices necessary to constitute a compliant multiple choice query. Direction indicates the following are required:

• Answer options should only include clinically relevant choices
• An option of “other” allowing the provider to specify with their own wording/answer
• Other answer options that may be used, but are not required include unknown, unable to determine, not clinically significant, integral to, unable to rule out, inherent to, or other similar wording
• No information related to answer impact to include reimbursement, quality measures, etc.

While preparing this brief, it came to the co-authors’ attention that some organizations were interpreting the answer of “unable to determine” as an uncertain diagnosis. The group strongly disagreed with this interpretation and clearly wrote, “Unable to determine is defined as the provider being clinically unable to determine if a diagnosis or further clarity can be provided in the documentation. This terminology does not equate to an ‘unable to rule out’ option and does not represent an uncertain diagnosis.”

The practice brief has evolved over the years, related to the setting and purpose and platform for which a query is deployed. The brief also speaks to query practices related to problem lists, templates, provider education, and the role of prior encounters in query. As with any reference, it should be considered when writing policy, evaluating commercial technology tools, educating, auditing functions, and of course daily practice in query. We ask you to review the brief, offer any comments, and practice compliant query in your daily work. After October 25, the authors will reconvene to review these comments, apply any changes felt relevant, and release the final version. You can access the guidelines here.

*© 2022 AHIMA and ACDIS with equal rights.

Editor’s note: Prescott is the interim director and director of CDI education for ACDIS, based in Middleton, Massachusetts. Contact her at lprescott@acdis.org.