10 Tips for Compliant Query Process Success
Composing a compliant query is the most important task for the querying professional. By including the following top 10 tips in your query process, drawn from the ACDIS/AHIMA industry standard Practice Brief, Guidelines for Achieving a Compliant Query Practice (2019 Update), you are well on the way to a successful querying practice and program success in this all-important facet of CDI.
1. A query should be brief and to the point, conveying only the indicators that are pertinent to the intended question. It is not advisable to include information that doesn’t add value or substance to the message of the query. The addition of unnecessary information adds more time for the provider to read through when time is a precious commodity that is best spent on patient care.
2. It is vital to include all relevant clinical indicators in the query. A query should be designed so that a provider does not have to refer to the medical record for any additional information. If all relevant clinical indicators are not included on the query, it could be viewed as purposeful selection and as such, leading the provider to a desired response.
3. There is nothing to gain by including clinical options in a multiple choice query that have been documented in the medical record. If the provider documented a particular diagnosis or condition once, the odds are great that option will be chosen again.
4. There is no minimum nor maximum number of options in a multiple-choice query. Every clinical option should be supported by relevant clinical indicators in the medical record, and that support must appear in the body of the query. Doing less can be seen as leading.
5. The query template should be editable to allow for the inclusion of only the options that are supported by relevant clinical indicators from the record.
6. As the healthcare environment shifts from a setting focus (hospital, office, clinic, etc.) to a patient focus, it has become necessary to look at the medical record across the continuum of care. Each encounter is a chapter in the story of the patient’s health status and a complete and precise depiction of that story is the goal. By using information from prior encounters as relevant clinical indicators in a query, that goal comes closer to fruition.
7. The only place a new (undocumented) diagnosis can appear is as an option in a multiple choice query. This makes sense because if a new, undocumented diagnosis appears anywhere else, such as the body/question of the multiple choice query, a yes/no or open-ended query, or the query title, it is viewed as the querying professional making a diagnosis, which is outside the scope of work of the querying professional.
8. It is necessary for the querying professional to leave contact information on the query, in case the provider wishes to discuss the query or obtain further information.
9. A verbal query is a great way to get an answer to the query while engaging with the provider. This is a perfect opportunity for sharing of information and mutual education. A compliant verbal query conversation should be memorialized in a timely manner to include the reason for the query, the clinical indicators, and the options provided, as well as the date and time of the conversation, the name of the engaged provider and the querying professional.
10. Provider education continues to be a critical component of the query process. By educating the providers on the basis for the query subject (teaching to fish) instead of asking the same query over and over again (giving a fish), you are setting the provider, and the program, up for success. The goal is to minimize queries while maintaining the highest level of medical record documentation integrity.
Do you have a 100% compliant query process in place? We can assist in evaluating your query process to ensure 100% compliance and can provide education surrounding compliant querying practices to help you reach your goal of program success.
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, CCDS-O
Mid-Revenue Cycle CDI Content Manager