Do Your Queries Follow the AHIMA Guidelines for Achieving a Compliant Query Practice?
Developed by AHIMA and ACDIS, the Guidelines for Achieving a Compliant Query Practice brief establishes industry-wide best practices for the clinical documentation query process. By following these practices, medical coders, CDI specialists, providers, and other healthcare professionals can expect a more streamlined, organized clarification process. And when the query process is more efficient, all parties involved stand to benefit.
The most recent update to the query practice brief came in 2022 at the AHIMA Global Conference. The 2022 update addresses query guidelines and templates, provider education, query technology, and more. Read below for a brief overview of the updated query guidelines.
AHIMA Query Guidelines
- Queries should include multiple choices for physicians to answer. Ensure the patient’s record features clinical indicators to support the options, including evidence for diagnosis answer options.
- The query title should not contain leading or impactful information.
- Include a clear, concise, and non-leading query statement.
- The supporting evidence for clinical indicators must be specific to the patient and episode of care. If a more complete or accurate diagnosis/procedure should be coded, the query must include supporting evidence to make the change.
- Avoid using query questions, statements, or answers that indicate an uncertain diagnosis – unless the provider has used a term of uncertainty when documenting a diagnosis.
Review the full query practice guidelines here.
When Should a Coder Query the Physician? And When NOT To Query?
- You need supporting documentation of diagnoses or conditions that are clinically evident but lack stated evidence.
- You need a resolution between providers for contradictory diagnostic or procedural documentation.
- You need clarification about the reason for the patient visit.
Review the additional instances of when to query here.
Do not query:
- If the provider can’t send clarification based on the patient’s chart.
- If there is no additional documentation to suggest that a code of a higher degree should be assigned.
- If the answer options within the query are not supported by documented clinical data.
Review the additional reasons when not to query here.
For additional support regarding the AHIMA guidelines for achieving a compliant query practice, review these additional resources:
- Top 5 Tips to Resolve ProFee Physician Discrepancies
- Case Study: To Query or Not to Query
- Know Your CDI Data: Statistics & Trends Analysis for Successful CDI Programs
- YES CDI Specialist: Liaison Between CDI & Coding
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