Q&A: Compliant query practice
Q: Our issue is that when constructing the query, the CDI specialist/coder is giving the appropriate responses to the physician, but when they choose to answer the query and click on choices, they are given a multitude of choices in the response section. The CDI team is thinking this is making our queries noncompliant being that those choices are all there, whether or not they’re clinically relevant. The HIM build team, however, is saying it is not noncompliant because those responses aren’t ever seen again when the physician chooses their response.
For example, with congestive heart failure (CHF), if it only meets the criteria for systolic, we give the choices for systolic and “other, please specify.” When the physician clicks on the responses, however, every form of heart failure a patient could have are embedded as answer options.
Response #1: What your CDI specialists present as options should be exactly memorialized in the health record with the options provided. Additionally, according to the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, you do not need to list all options; only the relevant options with supported clinical criteria for the diagnosis should be listed. Sending a query for a specific diagnosis and including the choice for “other” is sufficient.
At my organization, we have hardwired our queries to contain an option for “unable to determine” and “other” with a free text field for the provider. The rest of the options are selected by the CDI specialist sending the query only if the option makes sense with the clinical scenario.
Response #2: We are currently working with our IT department to get our query templates updated and compliant. They also told us that we are currently unable to modify the dropdown option within our templates. They have told us they think it will be an option with an upcoming upgrade but are not sure. Our staff has been using the templates when compliant, and then building their own DIY query within a blank query when the answer options in the preset template are not compliant.
Our IT department also did not agree with our suggested changes, so we sent them the updated ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief and offered insight into the new guidelines regarding appropriate and supported answer options.
Response #3: Our team had a similar discussion a few years back. The ACDIS/AHIMA practice brief instructs us to include clinically significant and reasonable option(s) as supported by clinical indicators in the health record, recognizing that occasionally there may be only one reasonable option. The CDI team at my organization only provides options within our queries that are supported within the query.
For your CHF example, if there is no support to include from the health record of any other type of CHF, we would not include this as an option. I would recommend including one of your health system’s compliance officers in the conversation as well. When auditing our CDI staff, we would consider additional or other types of heart failure to be noncompliant if included in the option. Lastly, in our audit we would ensure that all options presented to the provider are supported in the query. If an option is felt to be not supported within the query, we review the record and give feedback on what could have been added to support all offered options to the provider.
Response #4: If the provider is being given inappropriate choices at the time the query is presented, it would be noncompliant. The feedback given that it’s not discoverable so not to worry about it seems inappropriate as well. I would compare it to a verbal query where the CDI specialist tells the provider to write a certain diagnosis. We may not hear it or see it documented as occurring but, in the end, it would be considered noncompliant in my opinion as well.
Response #5: When the CDI team submits a query only choices specific to the case scenario are present, but when provider opens the form in the EHR all choices from the template pop-up?
It is not compliant to offer choices on the query that are not supported by clinical indicators. The query should stand on its own. We require our CDI specialists to edit the query question and choices every time prior to submitting, and queries are part of our medical record.
If the provider is seeing options on the query not supported by clinical indicators above prior to making their selection, it is not compliant.
Response #6: The ACDIS/AHIMA query practice brief describes that a query must be patient specific. The options given to the provider would be leading if not clinically supported. For example, it would be wrong to include an option of anemia due to chronic kidney disease (CKD) for a patient who does not have CKD!
It is okay that some cases may only have one viable option choice along of course with the option of other, if that is the only condition that fits that patient’s specific condition.
I totally agree with your example of CHF. It would not be appropriate/compliant to include every type of CHF if the patient is meeting criteria for systolic. The only option should be systolic and the applicable acuity. It would be noncompliant to include other options that do not meet the patient’s clinical indicators.
We have also had similar discussions with our coding partners at my facility and have provided education using the query practice brief as our standard.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and originally appeared in the CDI Leadership Insider, the monthly newsletter for members of the Leadership Council. For the purposes of this article, all Council member answers have been deidentified.