HCPro, JustCoding Inpatient - 2015 Issue 28 (July)
Q&A: Building a query for sepsis
July 29th, 2015
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Article Overview
This Q&A addresses a common CDI and coding scenario involving suspected sepsis or SIRS in the setting of infection. It explains the general compliance concerns around query construction, references AHIMA query guidance, and discusses the type of clinical support and treatment context that can justify a physician clarification query. The article is aimed at CDI specialists, coders, and documentation professionals who need to evaluate whether and how to query for an unlisted diagnosis.
Why This Topic Matters
Query compliance affects documentation integrity, physician communication, and downstream coding accuracy. Understanding the broad boundaries of when a clarification query may be appropriate helps CDI and coding professionals avoid leading language while still capturing clinically supported conditions.
What You Will Learn
- How compliant query practice is framed in a sepsis-related documentation scenario.
- What kinds of broad clinical indicators may be used to support a physician clarification query.
- Why existing conditions should be considered when evaluating whether sepsis is supported.
- How query examples are structured in a general CDI context.
Who Should Read This
- Clinical documentation integrity (CDI) specialists
- Medical coders
- Coding auditors
- Revenue cycle documentation staff
- Health information management professionals
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