Clinical Documentation Integrity: Overcoming Query Challenges

By By Susan Chapman, MA, MFA, PGYT for For The Record

A dozen best practices to help coding and CDI professionals create effective queries for accurate and comprehensive medical documentation.

Coding and clinical documentation integrity (CDI) professionals use queries to ensure diagnoses and procedures documented in the health record accurately reflect patient care. However, there are times when the health record is unclear, or there are gaps in documentation, and query authors need additional information from physicians.

Two documentation experts—Erica Remer, MD, CCDS, creator of Dr. Remer’s Documentation Modules, and Tammy Combs, RN, MSN, CDIP, CCS, CNE, an AHIMA-approved ICD-10-CM/PCS/CDI trainer—offer their insights on best practices when writing queries to help address, or avoid, potential challenges:

1. Choose the right audience: Coding and CDI professionals should select the correct health care provider to query based on their role and appropriateness, especially in cases of conflicting opinions.

2. Know what you’re asking and why: Understand the purpose and context of your query before approaching a health care provider for clarification. “This is important because it helps the author query in the right way that will elicit the best answer from the provider,” Remer explains. “The coding and CDI professionals present the clinical indicators and either provide choices and/or a free text option.”

3. Identify the type of query: Coding and CDI professionals should recognize whether they need more specificity, need to remove a diagnosis, or have a genuine question to ask, as this determines how to structure the query. “When clinical indicators do not seem to support a diagnosis, that is the time to use clinical validation queries. You want the provider to reconsider or improve the documentation to support the diagnosis,” Remer says.

4. Avoid leading: Coding and CDI professionals should not lead the provider to give a specific answer. “Leading means either directing providers to give a specific answer or giving them quality or reimbursement implications that also might lead them to pick a specific answer even if it’s not valid,” Remer explains. “Don’t include information about the potential impact of a diagnosis on reimbursement, quality scores, or other reportable data in your queries.”

“This is true for titles, too,” Combs adds. “Whatever title the provider sees cannot be leading, just like the query itself cannot be leading. Sometimes, coding and CDI professionals have queries with two titles, one that they can see in their view and one that the provider can see.”

5. Be concise: Provide all relevant clinical indicators clearly and concisely, as health care providers have limited time and attention. “You want the provider to understand exactly what’s being asked or what the need is in the documentation,” Combs offers. “Good query authors, once they write up that query, look at it and read through it to make sure it makes sense.

Remer further explains, “Not only is a provider’s time very limited but everyone’s attention span is short now. You need to give them what they need as quickly and precisely as possible without additional information that doesn’t help them make a good, thoughtful decision.”

6. Offer appropriate choices: When providing options in a query, ensure they all align with the clinical indicators and avoid including choices that are not clinically valid. “This is a corollary to being concise. You want to give providers appropriate choices. The misconception people have is that there are a certain number of choices you have to give, and that’s not true. You need to provide all of the choices that could match the clinical indicators,” Remer says.

Combs notes that multiple-choice queries are helpful. “When using multiple-choice queries, though, include an ‘other’ option, allowing providers to give additional details or specificity if necessary,” she says. “In multiple-choice queries, even when giving several diagnosis options, all of them should be supported by clinical evidence and presented clearly and concisely.”

7. Support the query with information from the health record: “Support your queries with facts and information directly extracted from the patient’s health record, avoiding opinions or assumptions,” Combs says. “Use clinical evidence in the query that is applicable to what’s being asked, what you know is the potential gap in the documentation. I’ve seen queries before where there’s too much clinical information. They pull in everything that might be related. This can be overwhelming to providers, so we definitely want the clinical evidence to be clear and relevant to support the need for the query.”

8. Limit repeated queries: Avoid repeatedly querying the same health care provider for the same question. “Once you’ve queried a provider and they’ve given you an answer, you can’t query them again if you don’t like the answer,” Remer says. “But if new information comes to light or you determine that someone else is the appropriate person to ask because you initially asked the wrong person, you can query again. Avoid asking the same person, hoping they’ll give you a different answer.”

9. Refer to official guidelines: Familiarize yourself with official coding and documentation guidelines to understand the importance of clinical validation and the need to resolve conflicts through queries.

ACDIS and AHIMA offer their joint “Guidelines for Achieving a Compliant Query Practice” on the AHIMA website. The practice brief “provides best practices for professionals in all health care settings who participate in query processes. Access to valuable [CDI] knowledge to” do the following:

• guide standardized query practices across the industry;
• serve as a reference tool for compliance and legal matters;
• inform external stakeholders and consultants; and
• empower your team members with the necessary information to excel in compliant query practices.₁

10. Template awareness: Query authors should know which query template to use for specific scenarios, ensuring they choose the most appropriate one. “Many programs are now using templates, and query authors should know exactly which template they should use,” Combs says. “Templates are good, and many organizations now have template libraries available. It helps the query author develop the query quickly in a very timely manner. The template includes the compliant components they need to be aware of, so knowing which is most appropriate for a particular scenario is very important. This goes back to the concern about leading titles. Coding and CDI professionals need a detailed title to identify the appropriate template to choose. But then, you’ve got to be a little more cautious on what title the provider can view to ensure the title is not leading.”

Remer adds, “The query author must be sure to edit the template as indicated, being sure to remove choices which are not clinically valid.”

AHIMA also offers a robust template library. Further information is available on the AHIMA website.

11. Review and collaborate: Regularly review and collaborate with health care providers to improve query quality and effectiveness. Incorporate feedback and make necessary adjustments.

12. Choose your battles wisely: Prioritize the queries you make, ensuring they are clinically significant and will contribute to the accurate representation of the patient’s condition. “When I’m looking at a record, I could probably find something to query about in every record,” Remer states. “But you only have so much capital with your providers, and you don’t want to query them for minor things or things that are not clinically significant. You can’t query on everything; you need to make sure that it’s important enough.”

These recommendations can provide useful guidance to help coding and CDI professionals create effective queries for accurate and comprehensive medical documentation. If questions arise, refer to the AHIMA/ACDIS practice brief for the latest information.

— Susan Chapman, MA, MFA, PGYT, is a Los Angeles-based freelance writer and editor.

Reference
1. Guidelines for achieving a compliant query practice. AHIMA website. https://www.ahima.org/landing-pages/ahima-acdis-guidelines-for-achieving-a-compliant-query-practice/