HCPro, JustCoding Inpatient - 2021 Issue 41 (October)
Three questions to consider before you query
October 12th, 2021
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Article Overview
This article is for CDI specialists, coders, and physician advisors who want to improve query quality and reduce unnecessary provider burden. It explains general considerations for when a query is appropriate, how to frame the underlying clinical question, and how to think about whether a finding is integral to a diagnosis. The discussion uses broad CDI and coding concepts, along with references to institutional clinical definitions and public health classification concepts, to help readers evaluate relevance before sending a query.
Why This Topic Matters
Query practices affect provider workflow, documentation quality, and the overall effectiveness of CDI and coding programs. Understanding when to query and how to frame questions can help reduce confusion, repeated follow-up, and avoidable friction with clinicians.
Article Sections
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Is this the correct timing?
Discusses when a query may be premature and the importance of allowing enough clinical information to accumulate before asking. It also touches on choosing the most appropriate clinician to receive the query.
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What’s the real question?
Explores how query wording can drift away from the actual documentation issue being addressed. It emphasizes identifying the underlying clinical question before writing the query.
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Is it integral?
Reviews the concept of integrality in relation to documentation review and distinguishes it from conditions that are merely associated. It also mentions the role of local institutional definitions in applying this concept.
What You Will Learn
- How to think about query timing in CDI workflows
- How to identify the underlying issue a query is meant to clarify
- How the concept of integrality affects documentation review
- Why local definitions and institutional practice can shape query evaluation
- How query placement and recipient selection can affect provider response
Who Should Read This
- Clinical documentation integrity specialists
- Medical coders
- CDI physician advisors
- HIM professionals
- Hospital compliance and documentation staff
Codes Discussed
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