Q&A: Re-querying when a provider chooses the ‘wrong’ query response

Q: Recently, we had a provider who responded to the multiple-choice query, but they didn’t pick the answer we wanted, even though it met the clinical criteria. I’ve been taught previously that when a physician selects a non-desirable answer, the CDI specialist should close the query and note that the physician disagreed. Would it be appropriate for the CDI specialist to go back and ask the provider about the clinical criteria they used to select their response?

A: This is a great question and one many CDI professionals wonder about. First, the short answer is no. A CDI specialist cannot go back and re-query a provider because they disagree with the provider’s response to a query or because a provider has selected another option even though the desired answer had valid clinical indicators. Doing so would be considered leading the provider to a desired answer, which would render your query as non-compliant. Remember, payers have legal access to all queries as a query is part of the legal record and can be discoverable in a court of law.

Although we often disagree with provider responses, CDI specialists are not acting as treating providers; we have no choice but to accept the query answer. The ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice—2019 update” states that, “Regardless of the method, a query must adhere to compliant, non-leading standards, permitting the provider of record to unbiasedly respond with a specific diagnosis or procedure.”

In addition to providing you with the short answer, I also want to show you when you CAN re-query on a topic that has already been queried and where to find that information so that, if this comes up in the future, you can have easy access to the answer. The 2019 query brief quoted above goes on to say the following on p. 5:

There may be times when a second query is needed to obtain further clarification of a previously answered query as additional information becomes available or as the clinical picture evolves. However, it is considered non-compliant to continue asking the same query to the same or multiple providers until a desired response is received.

I hope you find this information helpful!

Editor’s note: Dawn Valdez, RN, LNC, CCDS, CDIP, CDI education specialist at HCPro/ACDIS, which is based in Middleton, Massachusetts, answered this question. Contact her at dvaldez@acdis.org.