Q&A: Multiple questions on queries

Q: The ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice (2022 update) states that organizations should develop policies and procedures to manage and monitor query practice compliance. How many topics and/or questions do health systems allow on one query? Additionally, do they limit the volume of queries that may be communicated during the same encounter?

Response #1: As a general rule, our queries are focused on one diagnosis at a time. We believe this supports compliant query practice and is less confusing to providers. Additionally, it is very difficult to determine whether your query is “agreed” or “disagreed” if there are multiple components to the query.

As far as the number of queries during the same encounter, I would say we would rarely see over three queries on a chart. We don’t limit the number of queries because our ultimate goal is documentation accuracy. We also highly encourage verbal queries in complex situations which may involve clinical validation queries and/or sequential queries (meaning, you need to know the answer to one query before you can ask the next question).

Response #2: To stay compliant with queries and meet our software constraints, we want each query to address one diagnosis/or condition at a time. We do, however, allow our CDI specialists to ask for the condition, as well as the present on admission (POA) indicator in the same query depending on the case scenario and if appropriate. Pressure ulcers only address one pressure ulcer with its specific location per query, for example, but we may indicate POA if there is evidence on arrival so that both are captured together in one question.

There is no limit regarding the number of queries on the same encounter. The queries need to be relevant, and the CDI specialist uses their critical thinking and judgement to determine query topics and volume. We do not limit how many CC/MCCs can be captured per case. The goal is the integrity of the medical record and completeness. The team may, however, hold a query back if it is not impactful and DRG/severity of illness/risk of mortality are all maxed out (e.g., hypermagnesemia).

Response #3: We have found that query combos can confuse the provider and often lead to undesirable answers. If our CDI specialist is attempting to obtain two diagnoses with one query (cause and effect, relationship links, complications, etc.), these queries must go to a secondary CDI specialist for review prior to submission to a provider. This is to ensure the opening statement/question is clear and the query content/body is succinct. This process has helped our CDI team share query opportunities and sharpen query writing skills. Another benefit of this system is the ability for final editing. Offering a specialist the last chance to add relevant evidence or delete extraneous information prior to submitting to a provider has been quite helpful.

We try to limit three queries/chart, triaging by importance:

1. Coding Clinic “unassumed links” (e.g., complications, diabetes mellitus, cellulitis)
2. Quality queries (e.g., clarifying patient safety indicators/hospital-acquired conditions, pressure ulcers not documented by provider only wound care, progression of pressure ulcers)
3. MCCs
4. CCs
5. Hierarchical condition categories

Response #4: Our facility has decided that each query should be for one diagnosis only. We have found that queries containing multiple diagnoses confuse providers, leading to lower response rates. Also, limiting queries to one diagnosis allows us to get better data regarding queries (e.g., types of queries sent, volumes, queries to providers at an individual level, response/agree rates, etc.).

We do not limit the number of queries that are sent during an encounter, beyond requiring the condition queried for have an impact. However, since queries are a form of provider education, we suggest to our providers that “by doing better documentation, you can avoid receiving queries.”

Response #5: Regarding the number of topics/questions per query, we try to keep that at one. There are a few reasons behind that decision:

1. Data collection: Multiple questions per query muddies the data. 
2. Accuracy of responses: When multiple questions are put into one query, the odds of a provider giving a blanket response to all is increased versus having to respond to individual questions with individual answers.

Regarding the volume of queries per encounter, we do not have a hard and fast rule or written policy. Instead, we ask the team to use their critical thinking skills and judgement. In most cases there are a multitude of query opportunities that a CDI specialist could choose from. That has to be balanced with building relationships with the provider, along with recognizing the threat of query fatigue and physician burnout.

Bottom line is that we advise the team to “pick your battles.” When our charts are audited on the back end to look for missed opportunities, we also look at the bigger picture to see if the CDI specialist already placed two or three queries during the admission and maybe missed a query opportunity, versus no queries on the record and a query opportunity missed.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.