CCDSO

Query

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

Proper query ensures

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

When to query a provider

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 assignmen

Queries should not contain

Queries must not contain any information about their impact on reimbursement.

Queries should contain

all queries (no matter the format) should contain clinical indicators to support why the query was

Multiple Choice Queries should include

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

Yes / No Query

The guidance for the “yes/no” query format remains the same in the outpatient setting. 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

Can you use a yes/no query for a new diagnosis

No - New diagnoses cannot be achieved with a “yes/no” query; for this purpose, an open-ended or multiple-choice query format should be used.

ED query for POA

 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 practitioners

Policy for Query Process

The policy should indicate if the query is part of the patient’s permanent health record or stored as a separate business record. If the query form is not part of the health record, the policy should specify where it will be filed and the length of time it will be retained. It may be necessary to retain the query indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate query wording, even if they are not considered part of the legal health record

outpatient counterpart for UHDDS

The outpatient counterpart to the UHDDS is the Uniform Ambulatory Care Data Set (UACDS)

chronic conditions must be documented every ..

Within most risk-adjusted payment systems, certain chronic conditions must be documented every calendar year in order to be submitted for appropriate reimbursement.

what clinical guidelines does ACDIS recommend?

As a starting point, ACDIS recommends following evidence-based clinical practice (EBCP) guidelines. These provide information regarding diagnoses and treatment for specific conditions

example of problem list query

Dear Provider, Asthma was added to this patient’s problem list following her visit today. Would you please document how this diagnosis was addressed or managed? Thank you. Susan, CDI Specialist

problem list

CDI specialists can query the physician to remove conditions that are no longer being treated

can you code a diagnosis from a previous encounter

NO .. if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation

Query Template

Suggested template for all queries:

1. Patient identifiers.

2. Date of query.

3. Query: Clarification that is needed in the visit note.

4. Relevant clinical indicators: What is contained in the record (or problem list) in relation to the diagnosis needing clarification. Should state which notes in the medical record are being referenced, including the date of the note.

5. CDI reviewer: Include the name and contact number of the CDI specialist

Leading Query Example

Leading query example Note: The following is an example of a leading (i.e., noncompliant) query: Your patient, Mr. Jones, has a past medical history of CAD, CHF, and COPD. Please document these conditions during the encounter today. Thank you

Diabetes fasting glucose level

>126 mg

Diabetes two hour plasma glucose level

>200 mg

A1C measurement for Diabetes

• HbA1c measurements reflecting glucose levels over the preceding three months:

  • HbA1c ≥ 6.5% = diabetes

  • HbA1c 5.7%–6.4% = prediabetes or at risk of diabetes

AIC levels

Generally, an HbA1c level below 5.7% is desirable and considered normal.

Prediabetes is identified by an HbA1c level of 5.7%–6.4%.

Diabetes is diagnosed when the HbA1c level is 6.5% or higher.

The higher the HbA1c level, the stronger the indication of uncontrolled diabetes with hyperglycemia. An HbA1c of 7%–8.9% indicates uncon- trolled diabetes, and greater than 9% is considered critically high.

CKD GFR level

Decreased GFR < 60 mL/minute - at least 3 months

CKD objective measurements

• Albuminuria: albumin excretion rate (AER) > 30 mg/24 hours or albumin-to-creatinine ratio (ACR) > 30 mg/g 

• Abnormal urine sediment 

• Electrolyte and other abnormalities due to renal tubular disorders 

• Histological abnormalities noted in pathology 

• Structural abnormalities found in imaging 

• History of renal transplant 

CKD - Documentation may provide ACR categories, which are related to the extent of albuminuria (albumin in the urine) and used to support the presence of CKD

	ACR (mg/g)	Description
A1	< 30	Normal to mildly increased
A2	30–300	Moderately increased (CKD)
A3	> 300	Severely increased (CKD)

GFR for stage 1 CKD

90

GFR for stage 2 CKD

60 - 89

GFR for stage 3a CKD

45 - 59

GFR for stage 3b CKD

30 - 44

GFR for stage 4 CKD

15 - 29

GFR for stage 5 CKD

>15

what is TOAD?

The acronym TOAD is a quick mnemonic that providers can easily remember (Note: Providers frequently document but fail to assign the codes reporting dialysis dependence or noncompliance with dialysis each year.):

• Transplants

• Ostomies

• Amputations/AIDS

• Dialysis status

Diastolic HF

also called HF with preserved ejection fraction (HFpEF).

The ejection fraction (EF) measured by an echocardiogram will be 55% or higher

diastolic HF

Systolic HF

HF with reduced ejection fraction (HFrEF).

Systolic HF

The EF will be less than 40%

Heart failure mid-range EF (HFmrEF)

imaging criteria that have a left ventricular ejection fraction (LVEF) between 40% and 49%. 

End-stage HF

stage D of the ABCD classification of the American College of Cardiology (ACC)/American Heart Association (AHA) and class III–IV of the New York Heart Association (NYHA) functional classification

HF labs

In general, a BNP > 400 or NT-proBNP > 450 (in the absence of renal dysfunction) is an indicator of acute HF. 

BNP (HF)

B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) levels assist providers in differentiating between cardiac and noncardiac causes of dyspnea.

BNP levels

< 100 pg/mL: HF unlikely

> 400 pg/mL: HF likely

100–400 pg/mL: Apply clinical judgment

NT-proBNP

< 300 pg/mL: HF unlikely

Age < 50 and > 450 pg/mL: HF likely Age 50–75 and > 900 pg/mL: HF likely Age > 75 and > 1800 pg/mL: HF likely

medication for heart failure

Medication	Action
Angiotensin-converting enzyme (ACE) inhibitors (enalapril, lisinopril, captopril)	Vasodilatation—lowers blood pressure, improves blood flow, decreases workload of heart
Angiotensin II receptor blockers (losartan, valsartan, telmisartan)	Used when ACE inhibitors cannot be tolerated
Beta-blockers (carvedilol, metoprolol, bisoprolol)	Slows the heart rate, allowing for more efficient ventricular function
Diuretics (bumetanide, furosemide, spironolactone)	Works to increase diuresis or urine production
Digoxin (lanoxin)	Slows the heart rate and increases the strength of heart muscle contractions
Nitrates (nitroglycerin, isosorbide mononitrate or dinitrate)	Vasodilatation

Cardiologists classify the extent or severity of HF using two systems: 

The NYHA classification system and ACC/AHA classification system

HF NYHA classification system

• Class I: No limitation of physical activity 

• Class II: Slight limitation of physical activity 

• Class III: Marked limitation of physical activity 

• Class IV: Symptoms occur even at rest; discomfort with any physical activity 

HF ACC/AHA classification

ACC/AHA  Classification	Description	ICD-10-CM Indexing/Code
Stage A	High risk of HF but no structural heart disease or symptoms of HF	Z91.89, Other specified personal risk factors, not elsewhere classified (NEC)
Stage B	Structural heart disease but no symptoms of HF	See also Failure, heart, by type as diastolic or systolic I50.9 (heart failure, unspecified)
Stage C	Structural heart disease and symptoms of HF	See also Failure, heart, by type as diastolic or systolic I50.9 (heart failure, unspecified)
Stage D	Refractory HF requiring specialized interventions	See also Failure, heart, by type as diastolic or systolic, chronic I50.84 (end-stage heart failure)

HF query opportunities

Documentation of stage D or class III or IV HF should alert CDI to review the record to capture related comorbidities such as respiratory failure, acute kidney injury, myocardial infarction, arrhythmias, cardiomyopathy, congenital heart disease, valvular disease, or the presence of a left ventricular assist device. 

AF confirmed by

AF is confirmed by electrocardiogram, which will usually demonstrate an irregular rhythm, absence of P waves, inconsistent R-R interval, and rapid atrial activity, usually at the rate of 150–300 beats per minute. 

AF hemodynamically unstable

emergent electrical cardioversion is administered

AF initial treatment

aims to control the ventricular rate. Medications include calcium channel blockers, beta-blockers, or digoxin. If the patient remains in AF, medical or electrical cardioversion is used to restore normal sinus rhythm. Heparin is used for anticoagulation with warfarin following for three weeks.

AF characterization

It ultimately boils down to whether the condition has lasted less than seven days (paroxysmal), and, if longer, whether there has been a decision by the patient or provider to abandon cardioversion to sinus rhythm (permanent) or not (persistent).

chronic wound

present for 3 months

wound assessment

Wound assessments should describe the location, etiology of the wound, severity or depth, presence of undermining and/or tunneling, and evidence of infection

Braden scale

Braden Scale, a tool used to predict pressure ulcer risk.

severity of skin ulcer

Specifying the severity of non-pressure ulcers will impact CMS-HCC v28 RAF scores. Unspecified severity (depth of ulcer) will provide the lowest impact. This needed specificity for non-pressure ulcers of the skin is a new opportunity for risk impact in v28.

acute myocardial infarction (I21.9)

represents a patient who has experienced a myocardial infarction (MI) within the last 28 days and is still being monitored and treated,

I25.2 history of MI

I25.2 indicates a patient with a history of an MI with no current acute treatment needs.

History MI

Providers should make a habit of reporting a history of CVA (if no residuals are present) or report any sequelae such as apraxia, ataxia, cognitive defects, facial weakness, or language impairments (none of which contribute to risk adjustment) and mono-/hemiplegia or hemiparesis (both of which contribute to risk adjustment).