Q&A: Compliant query practice

CDI Strategies - Volume 14, Issue 45

Q: Does the ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” brief support queries that only list one diagnosis, “other,” and “unknown”? 

A: The 2019 ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” stresses that all choices should be possible from the clinical indicators present. This is what I use to guide query choices. There may be times when there is only one logical choice such as in abnormal lab values that point to only one condition.

Having said that, we always want to offer the choices of “other, please specify,” “clinically unable to determine,” or other terms that allow the provider to specify. By adding the choice of “other, please specify,” you are offering providers a choice to freely write whatever they wish in their response without leading them to any specific answer.

In contrast, for example, if I gave clinical indicators for sepsis on a query and only offered sepsis as a choice and did not provide any other choices at all, that would be considered leading the provider to an answer. So, offering the additional choices of “other, please specify,” (alternately, many people just use “other”) and “clinically unable to determine” help to prevent leading the provider. I’ve always used “other, please specify” because it gives a little more direction than just checking a box for “other” on a query.

In regards to the format, in addition to multiple choice queries, a CDI professional may also use an open-ended format by presenting the clinical indicators and asking for clarification on the condition being treated, monitored, etc., which is something that you or the provider may feel more comfortable with in certain scenarios.

For example, let’s look at metabolic encephalopathy. The documentation states that the patient presents with hypernatremia and altered mental status. As long as there are no other possible causes for the patient’s confusion in the documentation, then it is okay to use the hypernatremia as a choice. My recommendation, however, is to also include the choice of “other please specify,” “clinically unable to determine,” etc. In other words, CDI professionals do not have to come up with what has traditionally been known as a “throwaway” answer based on the content of the 2019 ACDIS/AHIMA query brief.

Lastly there are three areas that I would like to highlight from the 2019 ACDIS/AHIMA query brief in relation to query choices:

  1. “Avoid queries that: Fail to include clinical indicators that justify the query or justify the choices provided within a multiple-choice format.” (p. 5)
  2. “All clinically supported options should be included as well as additional options that permit the provider to craft their own alternate response. Options may include other, unknown, unable to determine, not clinically significant, integral to, or other similar wording.” (p. 9)
  3. “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.” (p. 9, emphasis added)

In conclusion, it is more important that a query demonstrate the appropriate clinical indicators and correctly identify possible choices rather than the number of choices that are listed as long as the query also contains additional options (such as “other, please specify”) that allow for the provider to freely write their answer if it’s not listed in the choices offered.

Editor’s Note: Dawn Valdez, RN, LNC, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.

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