HCPro, JustCoding Inpatient - 2018 Issue 18 (May)
Q&A: Citing clinical evidence in queries
May 1st, 2018
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Article Overview
This Q&A explains the topic of clinical evidence selection for physician queries, focusing on the amount and type of information that may be cited when supporting a suspected diagnosis. It is intended for coding and CDI professionals who write or review queries and need a general framework for balancing sufficient support with clarity. The article covers broad categories of evidence, examples of common documentation elements, and the role of facility-specific policy, without providing a prescriptive rule.
Why This Topic Matters
Clear query wording affects documentation quality and helps coding and CDI staff support compliant communication with providers. Understanding the broad evidence categories discussed in the article can help teams evaluate whether a query is appropriately supported.
What You Will Learn
- The general issue of how much clinical evidence to include in a query
- Common categories of clinical evidence that may be cited in support of a query
- How query support can vary depending on the clinical scenario
- Why facility-specific policies matter in query development
Who Should Read This
- Coders
- Clinical documentation integrity professionals
- Coding auditors
- Healthcare compliance staff
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