Note from the Instructor: Compliant query practice

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

I love to debate. I think when two people disagree a respectful discussion will result in one or both individuals learning something new. Interpretation of the ACDIS/AHIMA query practice brief published in 2019 often leads to some healthy debate. Of course, there are always shades of black and white, but with most examples of regulatory guidance you will find differing shades of grey, too.

Yesterday, I had the opportunity to talk query compliance with one of our ACDIS members, who is in the process of evaluating query practice across several campuses, and, of course, discovering a few shades of grey throughout his organization. This challenge can be difficult in a single hospital but is magnified when trying to coordinate teams across several facilities.

We see this often when teaching query compliance in our Boot Camps. Each facility has its own culture, its own lens. Some organizations examine query practice with a wider lens than others. Some organizations view query compliance with such a narrow lens that they may actually be non-compliant in an exaggerated effort to be compliant.

With any policies, I become concerned when I hear words such always or never. When we updated the jointly published ACDIS/AHIMA Guidelines for Compliant Query Practices in 2019, we thoughtfully worded the brief to allow flexibility. Every organization is unique, every setting has its own challenges. For example, a query in the outpatient setting is different than a query in the inpatient setting. Some organizations allow verbal queries, some do not. Some organizations use text-based physician communications, other embed queries within the medical record. If the rules are too tight, too directive it can be difficult for organizations to perform compliantly to the standard. The important piece to remember is that within your facility every effort should be applied to meet the directives within the brief, and all should interpret compliance consistently…using the same lens.

There are certain pieces of the brief that we can agree on, every query should:

• Be supported by relevant clinical indicators that support the premise of the question.
• Not indicate a financial incentive or motivation such as identification of CC/MCC/HCC or quality measure status.
• Use the proper format to fit the situation. For example, yes/no queries should never be used to obtain a new, undocumented diagnosis.
• Be unique to the specific patient, specific encounter. Templates must be customizable.

The bullets above are the easy part. The most difficult and the one most often “shady” is that queries should not lead the provider to a desired answer. We can all agree that you should never point out the desired answer with arrows, bold text, flashing lights and drum roll—those are the easy ones. But what about determining what answers (or how many) to provide in a multiple-choice query? That’s a more challenging distinction for CDI professionals to make.

The brief specifically states, “Multiple choice query formats should include clinically significant and reasonable option(s) as supported by clinical indicator(s) in the health record, recognizing that occasionally there may be only one reasonable option.”

Some organizations view this through a very narrow lens, and do not allow multiple-choice queries when there appears to be only one relevant choice. They either default to an open-ended format or will add a choice otherwise not supported by clinical indicators. I understand the default to open-ended queries but adding an unsupported possible answer in a multiple-choice query is leading in and of itself. This is an example of when one tries so hard to be compliant, they inadvertently become non-compliant in their practices.

Other organizations widen the lens. I have heard CDI staff say, “I am asking the query because there really is only one right answer, so there is no reason to add anything else to the list of choices.” That may be true for example, if the patient has a sodium level of 120, there really is only one choice. The patient is demonstrating hyponatremia. But what about the patient with clinical indicators supporting a severe level of malnutrition? Can you conclude that the patient meets a severe level so you should not include the choice of moderate?

I would likely include moderate in the list of choices, too. My thought is that I am only viewing the record, not the patient. The provider is assessing the patient directly and may understand their history better than I; and my “assessment” that only a severe level is supported may be misinformed.

I write this as an example, with a suggestion that organizations should regularly evaluate their query process for compliance.

Your policies should be reviewed annually. The individuals performing query should be audited on a regular basis. There should be regular discussions about what is compliant and what is not as a method of learning. There should be debate. Each organization should identify their areas of concern, their shades of grey, and work together to maintain consistent compliant query practice.

Editor’s note: Prescott is the CDI education director at HCPro. Contact her at lprescott@hcpro.com.