Compliant Query Formulation Flashcards
7 cards from real CCDS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Compliant Query Formulation flashcards as text
A CDI specialist wants to query about the specificity of a patient's anemia. Which query format is MOST compliant with AHIMA/ACDIS guidelines?
Answer: A multiple-choice query listing anemia types with a blank for 'other' and 'clinically undetermined'
A multiple-choice format with 'clinically undetermined' as an option is the compliant standard per AHIMA/ACDIS query guidelines.
Which of the following statements about query timing is MOST accurate under compliant query practices?
Answer: Queries may be issued concurrently during the encounter or retrospectively after discharge
Both concurrent (during admission) and retrospective (post-discharge) queries are permissible under compliant query guidelines.
A query is sent to a physician asking: 'Do you agree the patient has sepsis?' This query is problematic primarily because it:
Answer: Is a leading yes/no query that suggests a specific diagnosis without balanced options
Leading yes/no queries that suggest a specific answer are non-compliant because they bias the physician's response.
Under AHIMA's 2019 compliant query guidelines, which of the following must be included in every written query?
Answer: Patient name, account number or date of service, and the clinical indicators supporting the query
AHIMA guidelines require patient identifiers, relevant clinical indicators, and a clear question with balanced response options.
A CDI specialist documents in the query that clarifying a diagnosis to 'acute kidney injury' will increase reimbursement by $4,000. This practice is:
Answer: Non-compliant because queries must not reference financial impact or DRG changes
Including financial impact or DRG information in a query is non-compliant and can constitute improper influence on physician documentation.
Which scenario represents an APPROPRIATE use of a retrospective query?
Answer: Querying after discharge when clinical indicators in the record suggest a condition that was never explicitly documented
Retrospective queries are appropriate when the medical record contains clinical evidence of an undocumented condition affecting coding accuracy.
A physician responds to a query by writing 'per CDI' next to a newly added diagnosis. The CDI specialist should:
Answer: Ask the physician to re-document using their own clinical judgment without referencing the CDI query
Physician responses must reflect their own independent clinical judgment; 'per CDI' suggests the documentation may not meet compliance standards.