Guest post: Exploring the importance of best practices for queries

by Crystal Stalter, CDIP, CCS-P, CPC

Is there a best practice when writing a query? ACDIS and AHIMA believe there is, to the point of writing multiple articles and guidelines on the topic. So, what is the “best” way to query a physician and obtain additional information?

Let’s first look at the term “query” itself: It’s defined by AHIMA as “a provider communication tool used concurrently or retrospectively to obtain documentation clarification.” During review of a patient’s record, the coder or CDI specialist may need to have the physician further define, explain, or document the patient’s condition to properly assign the diagnosis and DRG. The query is the method for obtaining this information. It may be issued in writing or verbally, in letter or template form, or as a multiple-choice question or other type of checklist. Written queries can be printed or electronic.

A query should contain clinical information from the patient’s chart to clarify the question to the provider. The query should not be leading, but rather give the physician the opportunity to document based on his or her own interpretation of the information provided.

Each hospital should develop its own policy regarding the formal placement of the query in the chart and whether it becomes a permanent part of the patient record. Per AHIMA, if the hospital policy is to retain query documentation, legal council should be consulted for guidance regarding retention of queries, either in the patient’s legal health record or elsewhere.

Editor’s note: The full article was originally published on JustCoding. Stalter is the CDI manager for M*Modal in Pittsburgh. Contact her at crystal.stalter@mmodal.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.