CCDS Compliant Query Formulation 2 — Questions and Answers
Question 1: According to AHIMA/ACDIS query practice guidelines, which of the following query formats is MOST compliant?
- A yes/no query asking 'Does this patient have sepsis?'
- A multiple-choice query offering clinically appropriate diagnoses plus 'other' and 'clinically undetermined' (Correct answer)
- A query that states 'Please document sepsis to support the ICD-10 code'
- A verbal query with no documentation in the medical record
Correct answer: A multiple-choice query offering clinically appropriate diagnoses plus 'other' and 'clinically undetermined'
AHIMA/ACDIS guidelines require non-leading queries that offer balanced clinical options. Multiple-choice formats listing plausible diagnoses plus 'other' and 'clinically undetermined' meet this standard.
AHIMA and ACDIS jointly developed query practice standards that specify queries must be clinically based, non-leading, and allow for negative responses. The compliant multiple-choice format presents clinical indicators found in the record, lists diagnostically appropriate options, and always includes 'other' and 'clinically undetermined.' Queries that reference specific ICD-10 codes or DRG weights are explicitly prohibited.
Question 2: Which of the following query scenarios represents an INAPPROPRIATE use of a physician query?
- Querying to clarify whether anemia is acute blood loss anemia versus iron deficiency anemia
- Querying to document sepsis when the only basis is a desire to capture an MCC (Correct answer)
- Querying to confirm whether a wound infection meets criteria for postoperative wound dehiscence
- Querying to clarify the clinical significance of an abnormal laboratory finding
Correct answer: Querying to document sepsis when the only basis is a desire to capture an MCC
Queries must be based on clinical indicators in the record, not on financial motivations. Sending a query to capture an MCC designation for sepsis without any clinical indicators supporting sepsis is non-compliant and potentially fraudulent.
AHIMA/ACDIS guidelines and the False Claims Act prohibit queries sent for the sole purpose of financial gain without a clinical basis. CDI specialists must document the specific clinical indicators that prompted each query to demonstrate compliance during audits.
Question 3: When is a verbal physician query considered acceptable under CDI compliance standards?
- Never; all queries must be in written or electronic format
- For all queries, as verbal communication is faster and more efficient
- Only when the written query response is also documented in the medical record (Correct answer)
- For routine coding clarifications that do not affect DRG assignment
Correct answer: Only when the written query response is also documented in the medical record
Verbal queries may be used but are only acceptable if the physician's response and the clinical basis for the query are documented in the medical record.
AHIMA query guidelines do not prohibit verbal queries but require that the outcome be documented. The physician must add an addendum, attestation, or progress note to the medical record reflecting the clinical decision discussed verbally. Without written medical record documentation, the verbal query response cannot support code assignment.
Question 4: A CDI specialist sends a query for hypertensive heart disease. The physician responds 'clinically undetermined.' What is the correct action?
- Re-query the physician with more specific clinical indicators
- Accept the response and code without hypertensive heart disease (Correct answer)
- Code hypertensive heart disease anyway based on clinical indicators in the record
- Escalate to the chief medical officer to override the physician's response
Correct answer: Accept the response and code without hypertensive heart disease
When a physician responds 'clinically undetermined,' the CDI specialist must accept the response and code the case without the queried diagnosis. Physician responses including negative responses must be honored.
One hallmark of compliant query practice is that all physician responses including negative ones are accepted and coded accordingly. Re-querying on the same issue after a negative response is prohibited unless new clinical information has emerged.
Question 5: Which element is REQUIRED to be included in every compliant physician query?
- The specific ICD-10-CM code the CDI specialist is seeking
- The DRG impact of the physician's potential response
- Clinical indicators from the medical record that prompted the query (Correct answer)
- The identity of the insurance payer for the case
Correct answer: Clinical indicators from the medical record that prompted the query
Every compliant query must cite the specific clinical indicators from the medical record that prompted the question. This demonstrates that the query is clinically based and not financially motivated.
AHIMA/ACDIS guidelines specify that queries must include patient identifier, date of query, name and contact of querying clinician, clinical indicators from the record, the specific question being asked, and the response options. Including the DRG impact or specific ICD-10 codes is explicitly prohibited.
Question 6: A hospital's compliance audit finds that nearly all CDI queries result in documentation changes that increase DRG weight. What concern does this raise?
- The CDI program is performing at peak efficiency
- The query process may be leading or financially motivated, warranting a compliance review (Correct answer)
- The coding staff needs additional training on DRG assignment
- The hospital's payer mix likely skews toward more complex patients
Correct answer: The query process may be leading or financially motivated, warranting a compliance review
If nearly all queries result in DRG-increasing documentation changes, it may indicate that queries are being formulated in a leading manner or are clinically unjustified.
OIG and payer auditors look for patterns in CDI programs where queries consistently result in revenue-increasing documentation changes. Compliance best practices recommend tracking query outcomes by direction and investigating programs where outcomes are consistently revenue-increasing.
CCDS Compliant Query Formulation 2
According to AHIMA/ACDIS query practice guidelines, which of the following query formats is MOST compliant?