Q&A: Including references in a query

CDI Strategies - Volume 17, Issue 20

Q: I am working on streamlining our templates and would love to include the standard definitions of certain diagnoses, such as malnutrition, to help remind the providers of certain criteria within the body of the template. For instance, I would like to include the Global Leadership Initiative on Malnutrition (GLIM) criteria with references somewhere at the bottom, because we follow GLIM criteria as part of our policy. I was wondering if anyone has information regarding the compliance of this and whether it could be leading. Would including references and parameters within the body of a query be compliant?

A: There are a couple approaches to this question. Some organizations do not include definitions within their queries because they do not believe it is in CDI’s scope to define conditions for the provider. If there is a particular condition that needs a standardized definition, those CDI teams involve the physician advisor and medical staff leadership in defining conditions and in relaying those definitions to the providers.

Another option would be to provide standard definitions on the bottom of the standard query form as a reference for the provider to review (e.g., malnutrition ASPEN criteria, chronic kidney disease [CKD] stage criteria, acute renal failure criteria, sepsis, and sequential organ failure assessment information). The providers are, of course, free to answer whatever they wish.

Some organizations also provide industry best practice definitions to make it easier for providers. This is not considered leading; in fact, they use these when they perform clinical validations as well. The criteria are at the bottom, which states, “For reference only.”

When you identify the definition source, the provider knows what you are referencing and can make their own decision. When educating, you can tell providers, “The definition you use is up to you; we are just letting you know what definition we are looking at in order to ask the question.”

The ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice—2022 Update, p.13, says:

Including such information on a query is common. This practice allows providers ease in access to organizationally developed diagnostic criteria or industry evidence-based guidelines. This practice is not thought to be leading. The information should be provided without any indication of choice, meaning the information should not highlight, bold, or indicate a desired answer.

Editor’s note: This article was adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.

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