Knowledge Base Article

Over the years the American Health Information Management Association (AHIMA) has provided guidance on when and how to query for additional health record documentation in a compliant manner. They have recently published a new practice brief on “Guidelines for Achieving a Compliant Query Process” that augments and where applicable, supersedes prior AHIMA guidance on queries. MMP, Inc. encourages coders and clinical documentation specialists to read the AHIMA article for complete guidance and some excellent examples of compliant and non-compliant queries.

Key Points about Queries

The AHIMA article defines the purpose of a query as follows: “The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”

• Queries should be used to clarify documentation in the medical record for accurate code assignment, such as when
• Information is ambiguous, incomplete, or conflicting,
• Clinical indicators are not related to a specific condition,
• Clinical indicators to support a documented diagnosis are missing, or
• Greater specificity is needed.
• All queries must be accompanied by the relevant clinical indicator(s) that justify the need for the query. These indicators should be derived from the specific patient’s current episode of care and may contain elements from any part of the current medical record.
• Verbal queries should contain the same information and be in the same format as written queries.
• Queries should not indicate the impact on reimbursement or provider profiles.
• Queries should not be leading. A leading query is one that is
• Not supported by clinical indicators in the medical record and/or
• Directs or “leads” a provider to a specific diagnosis or procedure.

Query Formats

Although open-ended queries are preferred, “yes/no” queries and multiple choice queries are acceptable under certain circumstances.

Yes/no queries:

• Are appropriate for example in
• determining if a documented condition was present on admission (POA),
• substantiating a diagnosis that is already present in the medical record,
• establishing a cause and effect relationship, or
• resolving conflicting documentation.
• Should include additional options besides “yes” and “no” such as “clinically undetermined”, “other”, and “not clinically significant”.
• Should not be used to document a condition/diagnosis that is not already documented in the medical record, i.e. a new diagnosis based on clinical indicators.

Multiple choice queries:

• Are appropriate for example to document greater specificity.
• Should include clinically significant and reasonable options as supported by the clinical indicators.
• Should include additional options such as such as “clinically undetermined”, “other”, and “not clinically significant”.
• Should allow the addition of free text by the provider.

Note: It is acceptable to include a new diagnosis as an option in a multiple choice list if supported by the clinical indicators, since other options including “other” and free text are also available.

Handling Missing Clinical Indicators

Is a query appropriate when a diagnosis is documented that does not appear to be supported by clinical indicators or should this type of conflict be addressed through the facility’s escalation policy? This is something your hospital will have to decide how to handle. CMS recommends that all facilities have an escalation policy that may include referral to a physician advisor, chief medical officer, or other administrative personnel. Even if you use queries in some of these situations, escalation will be needed for more complex situations, for unanswered queries and to address any concerns regarding queries. An example of a query from the brief that addresses documented conditions without clinical indicators is:

QUERY: “Please review the laboratory section of the present record to confirm your discharge diagnosis of hypernatremia. Laboratory findings indicate a serum sodium of 120 mmol/L.”

Should the Query Be Part of Your Medical Record?

Your facility should have internal policies that address query retention and whether the query is to be a part of the patient’s permanent medical record or stored as a separate business document. Either way, remember that the medical record should include the clinical rationale for all diagnoses. Also, capturing the content of the query and the provider’s response supports the sequence of events so that documentation does not appear out of context.

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