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Q&A: Ensure query compliance by reviewing industry practice recommendations

Ask your question!

Ask your question!

Q: I was told that a multiple choice query should have at least four options. Keeping in mind that there may be only one reasonable option in a multiple choice query, what would be a good fourth option for a query about hyperkalemia if the other options are:

  1. Hyperkalemia
  2. Other
  3. Undetermined

A: There are many myths concerning compliant query practices so before automatically accepting a dictum of query parameters go back to the official sources to ensure compliance. By this I mean first reference the most recent guidance from the Association of Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS). AHIMA is one of the four cooperating parties (along with CMS, American Hospital Association, and the National Center for Health Statistics) so its recommendations have additional credence should auditors or other investigators question your CDI program practices.

According to the 2013 “Guidelines for Achieving a Compliant Query Practice:”

“Multiple-choice query formats should include clinically significant and reasonable options as supported by the clinical indicators within the medical record, recognizing that there may be only one reasonable option. Multiple-choice query formats should also include additional options such as ‘clinically undetermined’ and ‘other’ that would allow the provider to add free text. Additional options such as ‘not clinically significant’ and ‘integral to’ may be included on the query form if appropriate.”

If you still feel a fourth choice is needed perhaps the choice of “not clinically significant” could be offered. But this would depend on the circumstances of the particular patient encounter.

The 2013 practice brief also provides an option for yes/no queries. However, the brief does recommend that even in yes/no queries that additional options be included, similar to those recommended for multiple-choice queries.

“The ‘yes/no’ query format should be constructed to include the additional options associated with multiple-choice queries (i.e., ‘other,’ ‘clinically undetermined,’ and ‘not clinically significant’ and ‘integral to’). Yes/no queries may not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has yet to be documented in the health record. Also, new diagnoses cannot be derived from a yes/no query.”

Again, refer to the practice brief for additional circumstances where yes/no queries may be warranted and read up on previous practice brief recommendations for a better understanding of how queries should be formatted.



ACDIS and its parent company HCPro were once again pleased to attend the annual American Health Information Management Association’s meeting–its 86th–which took place in San Diego, California. We attended some informative sessions and met lots of great people including (from left): AHIMA Foundation Executive Director Dr. Bill Rudman, AHIMA CFO Denise Froemming, ACDIS/HCPro Events Operations Coordinator Alex Dataldo, ACDIS/HCPro Senior Marketing Manager Sheila McGrath, ACDIS Director Brian D. Murphy, ACDIS/HCPro National Accounts Manager Brooke Drozdowicz, HCPro National Account Manager Chris Ferris, AHIMA Foundation Board of Directors Chairman Dr. Warren Jones.



TBT: ACDIS/AHIMA ‘Guidelines for Achieving a Compliant Query Process’ outlines new query opportunities

CDI JournalEditor’s Note: In social media memes Throw-back Thursday (TBT) generally means someone has shared an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into the archives to highlight some salient CDI tid-bit rather than our fashion sense (or lack there-of).  Today, we’ve chosen to pluck information from the April 2013 edition of CDI Journal in which the ACDIS/AHIMA joint committee published the latest compliant query guidance Guidelines for Achieving a Compliant Query Process.” Specifically, the new practice brief offers new insight into how to compose multiple choice and “yes/no” queries in an effective and compliant manner. It also provides some additional definitions around the idea of what constitutes a “leading” query.

Guidelines for Achieving a Compliant Query Process

Although open-ended queries are preferred, multiple choice and “yes/no” queries are also acceptable under certain circumstances.

To support why a query was initiated, all queries must be accompanied by the relevant clinical indicator(s) that show why a more complete or accurate diagnosis or procedure is requested. Clinical indicators should be derived from the specific medical record under review and the unique episode of care. Clinical indicators supporting the query may include elements from the entire medical record, such as diagnostic findings and provider impressions. A query should include the clinical  indicators, and should not indicate the impact on reimbursement.

A leading query is one that is not supported by the clinical elements in  the health record and/or directs a provider to a specific diagnosis or procedure. The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format.

Multiple-choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record, recognizing that there may be only one reasonable option. As such, providing a new diagnosis as an option in a multiple choice list—as supported and substantiated by referenced clinical indicators from the health record—is not introducing new information. Multiple-choice query formats should also include additional options such as “clinically undetermined” and “other” that would allow the provider to add free text. Additional  options such as “not clinically significant” and “integral to” may be included on the query form if appropriate.

The “yes/no” query format should be  constructed to include the additional options associated with multiple choice queries (i.e., “other,” “clinically undetermined,” and “not clinically significant and integral to”). Yes/no queries may not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has yet to be documented in the health record. Also, new diagnoses cannot be derived from a yes/no query. In such circumstances, open-ended or multiple-choice query formats must be used. It is not considered leading to include a new diagnosis as part of a multiple-choice format when supported by clinical indicators.

Editor’s Note: Have a tough query situation your facility is dealing with? Join Cheryl Ericson, MS, RN, CCDS, CDIP, and Mark LeBlanc, RN, MBA, CCDS,  on Tuesday, June 10, to review best practices and sample queries to help you ensure your program is both compliant and effective in the 90-minute audio conference “Physician Queries: Ensure Effective, Compliant, Regulatory-based Clarifications.”

Happy Health Information Professionals Week and Certified Nurses Day!

Celebrate spring and professional achievement too!

Celebrate spring and professional achievement too!

Maybe it’s the promise of spring that has everyone in the mood to celebrate, after all tomorrow is the first day of that blissful season. Regardless, ACDIS stands at the ready to raise a toast to the two sets of professionals who support CDI efforts all year long.

First, this year’s Health Information Professionals Week takes place March 16th-22nd. This week provides an opportunity to showcase the thousands of HIM professionals who perform their duties throughout the year. ACDIS joins with AHIMA in its 25th anniversary celebration “Transforming Healthcare with Information.”

“The work HIM professionals do to ensure the integrity of health information is imperative to clinical and administrative decision making. Access to accurate information helps all of us make important decisions and leads to a healthy society,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA, in a press release.

AHIMA kicked off its celebrations earlier this with “Hill Day” where HIM professionals visit Washington D.C. for lectures and set aside time to meet with their Congressional representatives to talk about the importance of the role of HIM in today’s healthcare landscape.

Secondly, Certified Nurses Day takes place today Wednesday, March 19, as a national day to honor and recognize the important achievement of nursing specialty and subspecialty certification. Obtaining certification represents a milestone of personal excellence along one’s professional journey and we at ACDIS are proud to join our fellow professional organizations the American Nurses Credentialing Center (ANCC) and the American Association of Critical-Care Nurses (AACN), among others, in congratulating those nurses who go the extra mile to earn certification in their areas of specialty.
How many professionals from your state hold the CCDS certification?

1,800 hold the CCDS certification–are you ready to get yours?

Those who have chosen to sit for the Certified Clinical Documentation Specialist exam to obtain their CCDS credential understand the value of certification. Proudly displaying your CCDS pin and certificate not only demonstrates pride in your achievements but also illustrates to the world a personal dedication to industry standards and professionalism.

According to data collected by the American Board of Nursing Specialties in 2013, nurses in the U.S. and Canada held more than 683,684 certifications, an increase of more than 87,111 certifications compared to 2012 survey data. These certifications were granted by 27 different certifying organizations, and 122 different credentials designate these certifications.
For ACDIS’ part, the first CCDS exam was held in May 2009 and 39 months later, in August 2012, the 1,000th person passed. Just a few months later on November 22, the 1,500th person earned the CCDS.
Today, there are nearly 1,800 CCDS credentialed CDI professionals in the country more than 400 others registered to sit for the exam. A majority of CCDS holders are RNs, but ACDIS is proud to count many HIM professionals, as well as quality improvement personnel and physicians, among those who have earned the CCDS.
Whether you have your CCDS or another credential, ACDIS salutes you for professionalism and honor you for taking those next steps to demonstrate your commitment to the healthcare profession.
As a reminder, our parent company HCPro offers a number of ANCC-approved webinar programs including several which are also approved for CCDS, AAPC, and AHIMA credits. To learn more, visit
Upcoming programs include:






ICD-10 Coding Proficiency for Home Health: Coding Neurological Diagnoses, Circulatory Diagnoses, and Wounds – Part 3



ICD-10 Coding Proficiency for Home Health: Implementing an Action Plan – Part 4



Alternative Sanctions and CoP Compliance (WT)



Principal Diagnosis Selection: Essential guidelines for ICD-10 implementation  (WT)



Query Compliance: Tools to Identify Query Successes and Opportunities (WT)



Face-to-Face Physician Encounters: Strategies for Compliance (WT)



Quality Improvement Strategies (WT)



Management of Chronic Conditions in Homecare (WT)

CDI efforts take center stage at AHIMA conference



The 2013 AHIMA conference is in full swing today, but it’s educational sessions have been focused on clinical documentation improvement efforts since the conference opened on Saturday with sessions by Andrew Rothschild, MD, MS, MPH, CCDS, FTI Consulting, Dianne Haas, PhD, RN, TrustHCS, Brigid Caffrey, CCS, OptumInsight, and ACDIS book author Marion G. Kruse, RN, MBA. 

This morning there was a CDI networking breakfast and this afternoon sessions include:

ACDIS Director Brian Murphy arrived at the Atlanta, Georgia conference center last night and will be attending sessions, shaking hands at the ACDIS booth #1143, and hobnobbing at after-hours events tonight. So be sure to try and spot him! If you see him, be sure to take your photo with him and either tweet it @ACDISDirector or @ACDIS. If you’re not on Twitter, email it to Melissa Varnavas to post! Throughout the conference we’ll be giving away a free Boot Camp seat, a year’s membership to ACDIS, and other great items.

Tomorrow sessions include:

Although I wish I could be there, I know conference attendees will be learning a lot from our AHIMA colleagues and are in good hands with the tremendous HCPro staff in attendance. I can’t wait to hear all about it!

Guest Post: AHIMA director offers CDI insights

AHIMA releases CDI toolkit.

Endicott says increasing healthcare complexity requires CDI input.

By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA

Clinical documentation is the foundation of all aspects of healthcare, including data analysis, research, communication between caregivers, reimbursement, and most importantly, quality patient care.
The concept of clinical documentation improvement (CDI) is not new; however, the increasing complexity of the healthcare reimbursement system, quality initiatives, and the transition to ICD-10-CM/PCS put CDI programs in the spotlight. This article provides a high-level view of CDI programs, qualifications for CDI professionals, and future opportunities for this growing profession.
CDI programs
The purpose of a CDI program is to initiate concurrent and/or retrospective reviews of inpatient records to identify conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on the patient care units or remotely via the electronic health record (EHR).
The goal of these reviews is to identify clinical indicators that support the assignment of ICD-9-CM diagnosis and procedure codes. CDI professionals often use written queries in the health record to accomplish this goal. They may also use verbal and electronic communications. These efforts result in improved documentation, coding, reimbursement, and severity of illness/risk of mortality classifications.
Although CDI programs traditionally occur in the acute inpatient setting, they are being implemented in other healthcare settings as well, including acute rehabilitation hospitals and skilled nursing facilities.
CDI professionals
Individuals working in a CDI role need very strong clinical and analytical skills as well as expertise in coding. Most commonly, CDI professionals have several years of experience in inpatient coding or a nursing background. The essential coding skills that these individuals must possess include the following:
  • In-depth knowledge of ICD-9-CM guidelines and conventions
  • Access to and awareness of pertinent AHA Coding Clinic references
  • Understanding of the MS-DRG reimbursement system, including relevant MCCs and CCs that affect the MS-DRG assignment
CDI professionals must communicate effectively, both verbally and in writing, with clinical staff. CDI professionals routinely communicate with providers about documentation improvement and education, so it’s important that they are well-spoken and professional at all times to build trust and rapport with the clinical staff.
CDI professionals typically hold one or more of the following credentials:
  • Clinical Documentation Improvement Practitioner (CDIP)
  • Clinical Documentation Specialist (CCDS)
  • Registered Health Information Administrator (RHIA)
  • Registered Health Information Technician (RHIT)
  • Certified Coding Specialist (CCS)
Looking ahead to ICD-10-CM/PCS
The United States will transition from ICD-9-CM to ICD-10-CM/PCS on October 1, 2014. This transition is far more complicated than the annual code update to which coders and CDI professionals are accustomed. ICD-10-CM/PCS codes bring with them increased specificity, laterality, updated terminology, and new and revised guidelines. Hospitals should perform a gap analysis of physician documentation to identify opportunities for education and documentation improvement.
CDI professionals are the ideal individuals to educate physicians about the documentation requirements for these new code sets because they’ve already built trust and rapport with the clinical staff. CDI staff should be fully trained in both ICD-10-CM and ICD-10-PCS. This includes receiving in-depth training on the ICD-10-CM/PCS guidelines.
Future roles
Quality documentation is necessary in all healthcare settings. Outpatient settings, such as clinics, physician offices, and ambulatory surgery centers can reduce denials and improve data quality by employing CDI professionals to review records and identify deficiencies.
Other non-acute care settings can also benefit from a CDI program. These include long-term care, skilled nursing, home health, and rehabilitation centers. The future is bright for CDI professionals.
Editor’s Note: Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, is a director of HIM practice excellence at the American Health Information Management Association in Chicago. E-mail questions to Endicott at
This article was originally published on