Title: Module 6 Instructions
Course: HIM 3620 - TAACCCT Grant > Section: Module 6 - Queries

Readings

- Chapter 10: Documentation review and physician Queries
- Guidelines for Achieving a Compliant Query Practice article INSTRUCTOR: Input link to article from AHIMA Body of Knowledge Resources
- Physician Query Examples article

Lecture

The next few modules we will be discussing queries.  Let's start at the beginning....

A variety of tools should support the documentation improvement process of a CDI program.  Organizations may customize these tools to meet their particular needs.  For the purpose of this toolkit, the term query will be used to identify the physician communication tool used concurrently or retrospectively to obtain documentation clarification.  Other terms synonymous with "query" include clarification, clinical clarification, documentation alert, and documentation clarification.   The organization should define how queries will be developed and maintained int its CDI program (e.g., concurrent, retrospective, or a combination of both).  To meet the increased demands to produce accurate and timely coded data, many organizations choose to use query forms as a type of formal communication to ensure data integrity.

To support the request for documentation, CDI professionals should provide clinical indicators and/or medical evidence that prompted the request for clarification.  Some organizations may choose to use templates specific to certain diagnoses (e.g., heart failure) whereby the CDI professional checks the indicators, their locations within the health record, and supporting data.

A query is a routine communication and education tool used to advocate complete and compliant documentation. Although AHIMA refers to this communication to providers as a “query,” CDI programs may use different names, such as clinical clarification, documentation alerts, and documentation clarification. Regardless of what the communication is called, the query should adhere to the guidance outlined in the 2008 practice brief “Managing an Effective Query Process” and this current practice brief.

To support the request for documentation, CDI professionals should provide clinical indicators and/or medical evidence that prompted the request for clarification.  Some organizations may choose to use templates specific to certain diagnoses (e.g., heart failure) whereby the CDI professional checks the indicators, their locations within the health record, and supporting data.

Typical situations addressed by a query include presenting clinical indicators of an undocumented condition, requesting further specificity or the degree of severity of a documented condition, clarifying a potential cause and effect relationship, and addressing present on admission issues. The communication can include verbal and written queries, whether concurrent or retrospective. Some organizations may primarily rely on one strategy, while others may use a variety of query methods.

Assignment

Complete the Chapter 10 Quiz