The Effective Query Checklist

An Effective Checklist for Compliant Query

 

In recent times, there has been much emphasis placed on developing a compliant query and for good reason.

A compliant query is often the primary medical record communication tool that explains the appearance of documentation later in the admission.  For example, if there is clinical evidence of sepsis POA but no documentation of sepsis and a query is generated, agreed to, and documentation results, it could be questioned why documentation of sepsis appeared in the record several days later.  However, if a query exists, this completes the picture of that documentation gap with the resultant documentation.

A compliant query presents a complete picture to the provider by characterizing relevant clinical evidence and thus allows the provider to have all of the information needed to answer the question. Compliant queries can also be useful in denials, as the clinical evidence has already been gathered and is available as support.  More importantly, a compliant query seeks to clarify documentation gaps with the goal of a complete medical record that precisely depicts the patient encounter.

A checklist is a quick and easy method to assess whether a query is appropriate and compliant.

 

The Checklist

–          The query is appropriate for these situations:

o   Fits one of the situations outlined in the 2013/2016 ACDIS/AHIMA brief, Guidelines for Achieving a Compliant Query Practice, where a query might be appropriate.

o   No inclusion terms that would negate a query.  For example, HFrEF and HFpEF are inclusion terms under CHF in the classification.

o   Need to establish a causal relationship when there is no presumption using verbiage such as “with”, “in”, “due to” and “associated with” when appearing in a code title, in the alphabetic index as either the main term or subterm (excluding ‘NEC’), or an instructional note in the tabular list as outlined in I.A.14 “With”- and a guideline and/or documentation doesn’t negate the causal relationship.

o   Specificity needs to be obtained.

o   Conflicting documentation needs to have a decision by the attending provider.

 

–          All relevant clinical evidence is included

o   Provides strong support.

o   Ensures the provider has the complete picture.

o   Derived from the entire medical record.

 

–          The query is succinct

o   Information, i.e., clinical evidence, should be relevant

o   No extraneous information

o   Only one distinct clinical question per query.  POA status related to the one clinical question is acceptable.

–          No cloning/copying of paragraphs and/or sections of the EMR directly to the query.

 

–          Non-leading

o   No mention of impact on reimbursement or quality

o   Supported by all relevant clinical evidence/indicators

o   Does not direct the provider to a specific diagnosis or procedure

 

–          Formatted correctly

o   Not titled with a diagnosis that has yet to be documented in the record

o   Options are edited

o   Query is signed

o   Contact information is provided

 

–          Multiple choice query

o   Options are not already documented in the record

o   Options are clinically significant and reasonable

o   A code exists for every clinical option (for example, a code does not exist for urosepsis)

o   Options are clinically validated, i.e., there is documented support

o   Does not use the word “possible”

o   Contains options of “other” and “clinically undetermined”

o   If applicable and appropriate, contains options of “not clinically significant” and “integral to”

 

–          Yes/No query

o   Condition/diagnosis already documented in medical record

o   Contains options of “other” and “clinically undetermined”

o   If applicable and appropriate, contains options of “not clinically significant” and “integral to”

 

–          Verbal query

o   Written evidence of verbal query

o   Can be condensed but essence remains

o   Contains clinical evidence

o   Contains actual question posed

 

Feel free to utilize this checklist as is or add other points per your facility process.  Note: Although much of this checklist is applicable to the outpatient environment, it is recommended to refer to the 2018 ACDIS position paper, Queries in outpatient CDI: Developing a compliant, effective process for distinctions.

Wishing you success in CDI!

Respectfully,

Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP

Director of CDI Education

MedPartners

 

  • Resource: ACDIS/AHIMA. 2013. Updated 2016 Guidelines for Achieving a Compliant Query Practice. HCPro.
  • Resource: AHIMA. 2008. Managing an Effective Query Process
  • Resource: AHIMA. 2010. Guidance for Clinical Documentation Improvement Programs

 

Confidential Intellectual Property of AMN Healthcare

 

Apply for a Job with MedPartners

Looking for a New Career? We’d love to hear from you. Please click “apply” to submit a cover letter and resume.