Q&A: Compliant queries

Q: I have a question about the following query. If the response is B, can you still capture it as withdrawal?

Based on these indicators taken from the medical record, please clarify by documenting on this query form and/or in the progress note the condition being treated with a nicotine patch and nicotine gum in this patient referred to as a “smoker” in the history and physical documentation.

1. Nicotine/tobacco withdrawal
2. Prophylactic treatment of nicotine/tobacco withdrawal
3. Unable to determine
4. Other (please specify)

A: I like your query but, unfortunately, when treating something prophylactically, by definition we are preventing it from occurring. A condition that is being prophylactically treated should not be coded.

According to the 2016 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief, we only need to provide “reasonable options” in a query. “Reasonable options” are determined based on the clinical indicators present in the medical record and, sometimes, there is only one appropriate response based on the clinical indicators present.

We want the documentation to accurately reflect the true picture of what is going on with the patient during the episode of care that is under review, so if the patient is not experiencing withdrawals, and is only being treated prophylactically to prevent the withdrawals, that is what we want the documentation to reflect.

Here are some sample queries for this scenario:

Documentation indicates a 25-year history of smoking cigarettes. Patient admitted to unit after six hours in the ED. Nursing notes describe increased irritability and continued requests to be allowed to smoke. Vital signs indicate elevated heart rate and blood pressure readings as described by nursing notes. Upon admission telephone order obtained for nicotine patch. Please clarify the indication for nicotine patch.

1. Nicotine/tobacco withdrawal
2. Prophylactic treatment of nicotine/tobacco withdrawal
3. Unable to determine
4. Other (please specify)

You have ordered the application of a nicotine patch for this patient with a history of smoking cigarettes for 10 years. The H&P indicates a “habit of 2.5 packs a day”.  Nursing documentation in the ED and admitting unit describe the patient exhibiting anger and threatened discharge against medical advice. Nicotine patch applied 2 hours after admission. Later nursing notes indicate the patient is presenting in much calmer manner and cooperative with plan of care. Please clarify the condition you are treating with the application of the nicotine patch.

1. Nicotine/tobacco withdrawal
2. Prophylactic treatment of nicotine/tobacco withdrawal
3. Unable to determine
4. Other (please specify)

Editor’s note: Sharme Brodie, RN, CCDS, answered this question. Brodie is a CDI education specialist for ACDIS and HCPro in Middleton, Massachusetts. Contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com.