Last Week on CDI Talk: Leading clarifications and proper query examples
Editor’s Note: CDI Talk (2017 edit: now ACDIS Forum) is a networking forum for ACDIS members, in which members ask pressing questions and garner the opinion and expertise of their peers. Pediatric CDI Talk is a forum specifically designed for CDI specialists in pediatrics.
In one recent discussion on Pediatric CDI Talk, users discussed examples of malnutrition and acute respiratory failure query templates, as well as query compliance. The tips are applicable to both adult and pediatric CDI.
A good clarification summarizes the case and presents the clinical indicators are, says Katy Good, RN, BSN, CCDS, CCS, CDI Program Coordinator, and AHIMA Approved ICD-10CM/PCS Trainer at Flagstaff Medical Center in Arizona.
Format-wise, many providers prefer simple bullet points for a quick and easy read, says Good. However, some do prefer a narrative, so it is important for the CDI specialist to find out what each physician would like to see in a query. Good generally uses bullets, but will modify to a narrative approach if the query is unusual or complex, and if the narrative style query is more effective in a certain case.
The problem many CDI specialists face, Good says, is often properly wording and formatting the question(s). Any questions must not lead the physician to a particular diagnosis in any way. For example, the CDI specialist cannot ask the physician if a patient has a particular condition. Instead, they must ask the physician to clarify an existing condition with additional specificity, or ask what condition(s) is being treated. It is appropriate to provide options, Good says, but it is also important to include all reasonable options, and to allow the physician to provide an additional response such as “other” and “unable to determine.”
Here are some example queries (download the forms below under “attachments”). Though this was posted on Pediatric CDI Talk, the example queries are for the adult population, which is reflected in the clinical indicators.
In the first query about a malnutrition case, Good suggests including the clinical indicators used, making sure to note where in the record you found them. Then, ask if the physician can further specify the malnutrition as “mild,” “moderate,” “severe,” “other,” or “unable to determine. Be extremely careful when querying for malnutrition as various government agencies and auditors have targeted malnutrition and related activities. (Read a related article on the matter in the March 5 edition of CDI Strategies.)
The second query deals with clarifying a diagnosis. CDI specialists should never ask the provider if a patient has a certain condition. This could introduce a new diagnosis to the medical record and is considered leading. Try using a multiple choice query instead. For example, “Can you please clarify whether the patient is being evaluated/treated for: Acute respiratory failure, Chronic respiratory failure, Acute on chronic respiratory failure, Other, Unable to determine.”
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