Q&A: Organizing clinical validation queries

Q: What are ways to organize clinical validation queries to help ensure they are compliant?

A: Let’s look at a compliant query that was sent because the documented diagnosis seemed to lack sufficient clinical support.

Acute respiratory failure is documented on the H&P dated xx/xx and progress notes dated xx/xx and xx/xx.

Clinical Indicators: H&P indicates: Underlying pneumonia, respiratory rate 12, no accessory muscles usage, arterial blood gasses are pH of 7.40, pCO2 of 36, and pO2 of 75 on room air.

Based upon the clinical indicators above, please clarify the status of respiratory function:

• Acute respiratory failure ruled out
• Acute respiratory failure confirmed (please document additional supporting information or mitigating factors)
• Other explanation of clinical findings (please specify)

The first part of the query is a clear and concise citation of the documentation from the record in question. The query states that acute respiratory failure is documented on the H&P and progress notes, both with dates included as well. The clinical indicator section of the query includes underlying pneumonia, a respiratory rate of twelve, no accessory muscle usage, ABG values, and the fact that the patient was on room air. These clinical indicators strongly support the diagnosis under consideration despite needing clarification, and the query states exactly where the clinical indicators came from in the record, in this case, from the H&P.

The query goes on to ask the main question: Based upon the clinical indicators above, please clarify the status of the respiratory function. This question is easy for the provider to understand, and it is non-leading. Then the reasonable answer options are provided, which can be in any order per the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice.

If the respiratory failure is not supported, which is why this query was sent, it is okay to place the ruled out answer option at the top. The second option includes confirmation of the respiratory failure, but with a secondary question asking the provider to include more detail to support the diagnosis. Coders and CDI professionals are often not at the bedside, and therefore, they don't always get the full picture of the patient's status from the documentation alone, hence the second option asking which clinical indicators support the diagnosis. This is a great answer option to include in any validation query so that the provider is given a chance to further clarify a documented diagnosis and support it with their own personal rationale or definition. Finally, there is the essential option of other. With multiple choice queries, this is really the most important answer option in terms of compliance. Providers need the freedom to make any diagnosis they deem appropriate regardless of what is seen in the chart. This other option is the way to ensure provider autonomy in the process of responding to queries.

Here is an example very similar to the first, but it demonstrates how different formats are indeed acceptable.

Please clarify the status of acute respiratory function:

• Acute respiratory failure ruled out
• Acute respiratory failure confirmed (please document additional supporting information or mitigating factors)
• Other explanation of clinical findings (please specify)

Acute respiratory failure was documented on H&P dated xx/xx and progress notes dated xx/xx and xx/xx. Clinical Indicators: H&P indicates: Underlying pneumonia, respiratory rate 12, no accessory muscles usage, arterial blood gasses are pH of 7.40, pCO2 of 36, and pO2 of 75 on room air.

In the previous example, clinical indicators were listed first, followed by the question, and finally the response options. In this query, the question is at the top, followed by the response options and then the clinical indicators. Both formats are indeed acceptable per the compliant query practice brief.

Editor’s note: The Q&A was originally published in JustCoding. It was answered by Natalie Negro, MPH, BSN, RN, CCDS, FACHE, the corporate CDI manager at the Hospital of the University of Pennsylvania, during an HCPro webinar, “Comply with Me: A Journey to Compliant Query Practice.”