Physician Query Process Flashcards

A CDI professional reviews a record where the physician documented 'heart failure'. The echocardiogram shows an ejection fraction of 35% and the patient is on carvedilol and furosemide. Which of the following is the most compliant query to send to the physician?

Answer: "Based on the clinical indicators, can the type and acuity of the heart failure be further specified?"

This option is the most compliant because it is an open-ended, non-leading question that presents the need for clarification without suggesting a specific diagnosis or mentioning reimbursement. It allows the physician to use their clinical judgment to provide a more specific diagnosis based on the clinical indicators present in the record.

According to the AHIMA/ACDIS Practice Brief, which of the following is an essential element of a compliant multiple-choice query?

Answer: Providing an option such as 'other' or 'unable to determine' to allow the provider to add a free-text response.

The AHIMA/ACDIS guidelines state that a multiple-choice query should include options that are clinically supported by the health record and must provide a way for the physician to offer a different diagnosis or state they are unable to determine, ensuring the query is not restrictive or leading.

A CDI specialist identifies conflicting documentation in a patient's chart. The emergency department physician documented 'pneumonia', while the hospitalist's progress note suggests 'acute exacerbation of CHF'. What is the primary purpose of initiating a physician query in this scenario?

Answer: To resolve the discrepancy to ensure accurate code assignment and reflection of the patient's condition.

The primary goal of a query in the case of conflicting documentation is to seek clarification from the attending provider to resolve the inconsistency. This ensures that the final coded data accurately reflects the patient's condition and the care provided.

Which of the following situations would NOT be an appropriate reason to initiate a physician query?

Answer: The CDI specialist believes a more specific diagnosis could be documented to increase the Case Mix Index (CMI).

Queries should never be initiated solely to improve reimbursement or other reportable data. The purpose of a query is to clarify documentation based on clinical indicators present in the record, not to lead a physician to a diagnosis for financial gain.

A patient's lab results show a sodium level of 125 mEq/L (low), and the physician has documented 'electrolyte imbalance'. A CDI specialist wants to query for a more specific diagnosis. Which query format is most appropriate and compliant?

Answer: An open-ended query stating: 'The patient's sodium is 125 mEq/L. Based on your clinical judgment, can this condition be further specified?'

An open-ended query is the most compliant format in this situation. It presents the relevant clinical indicator (low sodium) and asks the physician to use their clinical judgment to provide a more specific diagnosis without leading them. A Yes/No query for a new diagnosis is non-compliant, and a multiple-choice query must only include clinically relevant options.

What is the best practice for a CDI department to follow when a physician consistently does not respond to queries?

Answer: Implement and follow a formal escalation policy that may involve a physician advisor.

The 2022 AHIMA/ACDIS Practice Brief recommends that organizations have an escalation process for unanswered queries. This process is not meant to be punitive but to facilitate communication and education, often involving a physician advisor or department leadership to address concerns and reinforce the importance of complete documentation.