It takes a team: Collaborating with CDI professionals to achieve an effective query process

Why This Topic Matters

Query practices affect documentation quality, coding accuracy, compliance, and audit readiness. Understanding the general guidance from AHIMA and ACDIS helps CDI and coding teams align their processes and reduce documentation-related risk.

Article Sections

1. CDI and coding collaboration

   Introduces how clinical documentation integrity work has changed the relationship between CDI professionals and coding staff. It also notes where CDI programs may be located within an organization.

2. AHIMA guidance and early query best practices

   Summarizes AHIMA publications and committee work related to documentation improvement and query practices. This section discusses how the guidance fit into broader CDI program structure and staffing considerations.

3. Verbal query considerations

   Explains the role of verbal queries in CDI workflows and the need for organizational policies, training, and monitoring. It also addresses the general compliance and communication concerns associated with this query format.

4. Joint ACDIS/AHIMA query guidance

   Reviews the joint practice brief and its updates, including its scope for inpatient and outpatient settings. It also describes how the guidance aligns with official coding and documentation resources.

5. Query formats, retention, and audit issues

   Covers the types of query formats identified in the guidance, along with policy considerations for retention and recordkeeping. It also mentions how query documentation may relate to audits and organizational record policies.