Q&A: Photos in queries

Q: A CDI specialist asked me if they could put a photo in a query. I’m used to noting in the query where in the chart the provider can find the photo, but I have never actually put a photo in the query itself. Is this allowed?

A: This is a great question, and the short answer is yes. No question regarding queries, however, can be answered without applying compliance principles. The clinical indicators and clinically relevant documentation taken directly from the medical record—used to support the need for provider clarification—are among the most critical components of a strong, compliant query.

When clinical documentation includes photos—such as images of wounds, ulcers, or deep tissue injuries—incorporating those images into the query can provide valuable clinical context. Photos can help the provider make objective clinical judgments regarding the diagnosis or needed specificity.

As with all clinical indicators used to support a query, you should cite the date, time, and location of the documentation in the medical record, without adding any subjective interpretation. Queries should never reference reimbursement, quality measures, or reporting initiatives, as this may inappropriately influence the provider’s response

Including relevant clinical indicators and documentation from across the medical record strengthens provider engagement and satisfaction. When photographs are part of the patient’s record, adding them to the query helps illustrate the patient’s condition and the resources required for care. Strong clinical indicators form the foundation for clinically supported provider response options, ultimately promoting accurate coding and appropriate severity and risk capture.

Editor’s note: Sarah Matacale, BSN, RN, CCS, CCDS, the query education and compliance specialist at HCPro, ACDIS, and AHIMA, answered this question. Contact her at sarah.matacale@hcpro.com.