Q&A: Multiple choice options on query templates

March 14, 2013

Q: Our CDI department is developing clarification forms and I have voiced concern with some of the templates. For example, the anemia clarification lists many possible diagnoses including aplastic anemia. If the listed condition would not be clinically acceptable based on the clinical indicators and treatment, should this diagnosis even be listed? I did raise the issue with our physician advisor and he is concerned with the forms, too. Personally, I feel we should not list diagnoses that are not clinically accurate for the specific case.

A: The AHIMA query practice briefs (the latest created in affiliation with ACDIS, Guidelines for Achieving a Compliant Query Practice, published in February) state that “reasonable” diagnoses must be listed in multiple choice queries. With that reference in mind, it is therefore inappropriate to include options on a query that are not supported by clinical indicators.

Although it is good those creating the query templates want to be as inclusive of as many types of anemia as possible, sometimes there is only one appropriate/relevant diagnosis. In such situations, it is okay for the query form to have only one specific diagnosis option as long as the form also includes options for “other,” with a line for comments, and “unable to determine.” The risk with query templates is that there needs to be a way to exclude information not applicable to a particular patient during a specific episode of care; the CDI specialist/coder needs to have the ability to edit/customize the template to suit the situation.

Creation of query templates have many benefits, however.

For starters, they provide a comprehensive starting point for the CDI specialist to work from. In a situation where an anemia query is warranted the CDI specialist could pull up the query template and adapt it to that particular patient’s medical record, including relevant clinical indicators and eliminating inappropriate options.

Furthermore, when CDI professionals include multi disciplinary members in the query creation process such efforts can prove educational for all involved. Physicians can offer clinical, diagnostic insight and HIM professionals may offer insight into coding nuances. Such inclusionary efforts at the outset also help to ensure all vested parties work together. In short, it can help ensure support for the CDI program and its documentation improvement efforts.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question which was originally published on the ACDIS Blog. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.

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