Q&A: Citing clinical evidence in queries

CDI Blog - Volume 11, Issue 116

Q: Our coders are having trouble determining how much clinical evidence to cite in our queries. Is there a general rule for how much to include?

A: Unfortunately, there is no exact answer when determining how much clinical evidence to include in a query. The key is finding the “sweet spot” wherein there is enough evidence to support a given diagnosis without overwhelming the reader.

Clinical evidence should generally include information from some or all of the following areas:

  • Sign and symptoms with duration
  • Diagnostic test results
  • Lab findings
  • Findings of consultants
  • Treatment performed

For example, when writing a query for pneumonia, the following information should be included:

  • Signs and symptoms: Fever 101°, green sputum, cough for a week
  • Diagnostic test results: Chest x-ray with left lower lobe infiltrate
  • Lab findings: White blood cell count of 14,000
  • Treatment: Started on Levaquin intravenous piggyback

Notice that this example did not include multiple sets of vital signs, as the diagnosis of pneumonia is made primarily based on signs and symptoms and radiological findings. Some diagnoses are less straightforward and require more clinical evidence to write a compliant query.

For example, when writing a query for a suspected case of acute renal failure, more in-depth information may be needed, with the treatment and outcome tied together, such as the following:

  • Signs and symptoms: Severe nausea and vomiting for one week and unable to keep down fluids. History of normal creatinine values prior to admission.
  • Lab findings: Creatinine 3.6 at admission and decreased to 1.2 after 24 hours of IV fluid boluses.
  • Findings of consultants: The nephrologist states “renal failure.”

Those new to the coding profession often struggle to determine the amount and type of clinical evidence to include with a query, and facility-specific policies can help provide instruction on this.

Editor’s Note: This article originally appeared in JustCoding. This Q&A was adapted from the book The Coder’s Guide to Physician Queries by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, with contributions from Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE.

Found in Categories: 
Ask ACDIS, Physician Queries