Q&A: Responding to additional ‘leading’ concerns
Q: I am concerned about the way we are being taught to write queries; it feels counter to the way I learned at the CDI Boot Camp and the materials I have read via ACDIS. For example, the query lists the appropriate clinical indicators from the record which would support a diagnosis of acute respiratory failure, but only offers two options for the physician: “acute respiratory failure” and “other.”
I worry that this could be construed as “leading.” Can you help point me to materials where I can better define this?
A: The question of crafting non-leading queries is a defining theme of the joint ACDIS and AHIMA 2013 publication of “Guidelines for Achieving a Compliant Query Practice.” Its opening lines state:
“In court an attorney can’t ‘lead’ a witness to a statement. In hospitals, coders and clinical documentation specialists can’t lead healthcare providers with queries.”
Print a copy of the new query practice brief and share copies with your facility CDI team. Although the new brief does allow for “yes/no” queries beyond the scope of present on admission (POA) status, its use is still limited to situations where a provider has already documented a diagnosis that needs more clarification such as its relationship to another condition or verification by the attending provider. The yes/no query format isn’t acceptable when only listing clinical indicators as would be the case when trying to solicit documentation of the diagnosis of acute respiratory failure.
Although open ended queries are the preferable format when eliciting a new diagnosis, the brief did clarify misperceptions regarding the use of multiple choice queries in these types of situations. Specifically, a diagnosis not already documented in the health record can be listed as a multiple choice option as long as it is supported by clinical indicator(s) in the health record.
The concept of introducing new information would apply if a new (e.g., not already documented within the health record) diagnosis appeared in the stem of the question rather than as a choice.
When crafting possible responses to a multiple choice query, the brief reinforces that all relevant diagnoses supported by the clinical indictors should be listed as options keeping in mind that sometimes there may only be one relevant diagnosis, but that “other” and “unable to determine” should always be an option for the provider.
As such, it is not necessary to list diagnoses without designation as a complicating condition (CC) or major complicating condition (MCC) if the clinical indicators do not support those diagnoses as a realistic diagnosis/option to avoid “leading” the provider. Additionally, the brief highlights the reason or support for the query is just as important, if not more important, than the query format. Best practice is to use common industry standards as clinical indicator(s) before querying for a particular diagnosis.
Regarding the diagnosis of “acute respiratory failure,” there are other diagnoses that may also be relevant depending on the severity of the indicators (e.g, acute pulmonary insufficiency, hypoxia, etc.). The query needs to be specific to the patient so that not all of your respiratory failure queries read exactly same. Make sure the possible multiple choice options reflect the relevant clinical indicators. For example, if the patient initially had a room air pulse oxygen of 90% without tachypnea or other similar symptoms and responded to 2 L/min of oxygen via nasal cannula with a pulse oxygen of 98%, this patient is unlikely to be experiencing acute respiratory failure.
Although the ACDIS/AHIMA guidance is non-binding/non-legal in nature, it does represent the culmination of industry best practices. Furthermore, both the ACDIS and AHIMA code of ethics calls on professionals to act in a manner reflective of the best interest of the profession, the institution, and most importantly the patient. The CDI team should work with physicians, coders, and other professionals within their facilities to develop compliant queries which reflect best practices from all perspectives.
Most importantly, your organization has to be comfortable with the level of “risk” or “vulnerability” associated with your querying process if ever investigated. Recovery Auditors and others are increasingly asking for queries associated with the medical record and, as illustrated by several cases (a Department of Justice settlement for $8.9 million, a Maryland qui tam case settled for nearly $3 million among others. You can review these related powerpoint presentations from previous ACDIS conferences in the Forms & Tools Library or review the evolution of the query practice in the new Physician Queries Handbook, Second Edition).
Hope this helps!