Q&A: Query compliance
Q: If a provider answers a query and the response requires further clarification, is it compliant to contact the provider by phone or other outside query method, have a conversation with the provider, and then ask/encourage them to add to their note without documentation regarding the outside query method?
A: It can be challenging to answer these types of questions without the specifics, as each clinical scenario, query formation, and response is different. However, we can address your concern by citing the guidance provided in the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief: It is noncompliant to lead the provider to a desired response. Educating the provider regarding code assignment, clinical/coding considerations, etc. is valuable but must occur in an educational setting; educating the provider within the query, whether verbal or written, would be leading.
Query format and response options are important to consider. For a multiple-choice query to be compliant, “other” must be included as an option, allowing the provider to write in their own response if the other response options do not offer diagnoses that align with the provider’s professional judgment. We understand that sometimes the provider’s write-in response may not align with code assignment. If you obtained a valid/codable diagnosis from the provider and are looking to further specify the diagnosis obtained, another query for specificity can be offered but only if that specificity was NOT provided in the original query.
The ACDIS/AHIMA query practice brief says the following:
It is non-compliant to continue sending the same query to the same or multiple providers until a desired response is received… If subsequent information is conflicting with the query response, additional clarification [query] may be needed.
Specifically regarding verbal queries, it says:
[T]hey should be recorded per organizational policy including documentation of the conversations that occur regarding documentation of reportable conditions/procedures. Conversations should be non-leading, including all appropriate clinical indicator(s) and all plausible options. In capturing the essence of the verbal discussion, timely notation of the reason for the query (exact date/time and signature), clinical indicator(s), and options provided should be recorded and tracked in the same manner as written queries. This would allow verbal queries to be discoverable to other departments and external agencies. A response to a verbal query must be documented in the permanent health record in order to be coded.
Querying is the compliant way for CDI specialists to communicate with the provider to clarify or specify the clinical information and documentation in the record. The ACDIS/AHIMA query practice brief should be referred to when issuing queries or formulating organizational policy and procedures, or when concerns arise regarding compliant practice.
Editor’s note: Kelly Rice, RN, BSN, MSHI, CCDS, CDIP, CCS, CRC, a CDI education specialist for ACDIS/HCPro, answered this question. Contact her at Kelly.rice@hcpro.com.