Q&A: Queries with prior health record information

Q: How might compliant queries look when information from prior health records is included?

A: Here is an example of a query that utilizes information from a previous health record in order to support a higher level of detail for a diagnosis relevant to the current admission.

Clinical indicators: Documentation in the progress note mm/dd/year indicates renal dosing applied to Metronidazole dosing. Current H&P mm/dd/year states CKD, but no stage is documented. Previous encounter discharge summary (dated xx/xx) documents CKD stage 4, trending eGFR (dates x/xx, x/xx, x/xx) ranging 17-20 mL/min.

Please clarify the staging of the CKD:

• CKD, stage 4
• Other explanation of clinical findings (please specify)
• Clinically undetermined

Clinical indicators cited in this query include documentation of renal dosing, current documentation of CKD but with no stage, a citation from a previous encounter with CKD stage 4 specified, and a trending GFR range.

The query asks the provider to clarify the staging of the CKD but did not list every stage of CKD as an answer option. Coders only need to supply the answer options that are clinically supported. An option for other and clinically undetermined are important when querying for a diagnosis where having a known baseline is essential to the diagnostic process (as with CKD). Providers will still need the freedom to make any diagnosis they deem appropriate regardless of what is seen in the chart.

Here is another example of a case that uses evidence from a prior health record to help specify a condition that is relevant to the current encounter.

Acute congestive heart failure was documented on progress note dated xx/xx.

Clinical indicators: Echo from last week’s office visit indicates ejection fraction of 35% and diastolic dysfunction.

Please further specify the diagnosis of heart failure:

• Acute systolic congestive heart failure
• Acute systolic and diastolic congestive heart failure (combined)
• Other explanation of clinical findings (please specify)

The query states acute CHF was documented on a dated progress note as well as recent clinical indicators. The question asks for further specificity regarding the heart failure, and the answer options include acute CHF and, of course, the other option. Chronic CHF options were not included because acute heart failure was documented this visit. The professional who authored this query should have certainly validated the acute aspect of this diagnosis to make sure that the treatments and indicators supported this level of acuity to rule out the chronic options. Acute diastolic heart failure was also not included since the ejection fraction is low enough to exclude that as a clinically reasonable and supportable response option.

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