ACDIS Outpatient Query

Outpatient encounters move at a much faster pace than

Outpatient encounters move at a much faster pace than

the inpatient arena, meaning communication with providers must be timely and efficient

Concurrent record review is challenging in the outpatient setting due to

the compressed nature of encounters and use of the problem list

Retrospective reviews allow for a review of a large number of records,

but this can burden the provider with multiple queries to answer

reviews are often performed prospectively, or prior to an encounter, to allow for providers

to be queried before the patient has been seen (letting providers answer the query during the actual patient encounter).

The jointly published AHIMA/ ACDIS Guidelines for Achieving an Effective Query Practice (first published in 2013, then updated in 2016)

set the standard for query practice within the inpatient setting.

The AHIMA/ACDIS practice brief describes a query as “a communication tool used to clarify documentation within the health record for accurate code assignment. The desired outcome for a query

is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”

A proper query process ensures that appropriate

documentation appears in the health record.

Personnel performing the query function should focus on a compliant query practice

and content reflective of appropriate clinical indicators to support a query

CDI professionals should query a provider when the medical record documentation:

■ Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent

■ Describes or is associated with clinical indicators but does not have a definitive relationship to an underlying diagnosis

■ Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure

■ Provides a diagnosis without underlying clinical validation

■ Is unclear regarding present on admission (POA) indicator assignment

Queries must not contain any information

about their impact on reimbursement

According to Guidelines for Achieving a Compliant Query Practice, “a leading query is one that is not supported by the clinical elements in the health record and/or

directs a provider to a specific diagnosis or procedure.”

Whether inpatient or outpatient, all queries (no matter the format) should contain

clinical indicators to support why the query was initiated

The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the

query format

Clinical indicators supporting the query may include elements from

the entire medical record, such as diagnostic findings and provider impressions.”

outpatient CDI team may need to reference labs within the query

to support why further clarification was initiated.

Open-ended, multiple-choice, and “yes/no” query formats

are acceptable in the outpatient setting

Multiple-choice query formats should always include

“clinically significant and reasonable options as supported by clinical indicators in the health record.”

Additional options such as “clinically undetermined” and “other” should be included in multiple-choice query formats

so that providers can add free text if the options provided are not applicable.

A “yes/no” query should not be used in circumstances where only clinical indicators of a condition are present

and the condition/diagnosis has not been documented in the medical record

New diagnoses cannot be achieved with a “yes/no” query;

for this purpose, an open-ended or multiple-choice query format should be used.

The guidance within this practice brief relating to POA status using the “yes/no” format will not apply to most outpatient settings, which often do not require the reporting of POA status. An exception

is the ED, as some ED visits lead to inpatient admissions, making ED documentation vital for the assignment of POA indicators.

it may be appropriate for some POA “yes/no” queries to be initiated in the ED setting under the following circumstances

Substantiating or further specifying a diagnosis that is already present in the health record (i.e., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician

Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings (i.e., hypertension and congestive heart failure, diabetes mellitus, and chronic kidney disease)

Resolving conflicting documentation from multiple practitioner

it remains best practice to capture all verbal and/or written queries

(both question and answer) in the outpatient setting

If a provider responds to a query within a medical record and there are no clinical indicators supporting the response, ask the provider

to document his or her clinical rationale for the diagnosis within the health record or on the query form (either are acceptable, if the query form is retained as a permanent part of the record).