The Coder & the Compliant Query

In this month’s article, we are going to look at what you need to know to prepare for the CCS/CCSP exam about the coder’s role as it relates to compliance in physician query process. In the CCS/CCSP Examination Content Outlines, compliance is the last domain of each outline, but compliance expectations are scattered throughout most of the domains in both exam content outlines. Task 4, Compose a compliant physician query is a new addition to Domain I of the CCS Examination Content Outline. For those of you preparing for the CCS-P exam, this task has not been added to the CCS-P Examination Content Outline – yet. The outpatient setting is not exempt from compliance accountability. Verbal communications between coding staff and the practitioner on diagnostic tests, treatments and other clinically relevant information needed in the coding process are common in the outpatient setting. Clinical documentation improvement programs are being implemented in the outpatient setting. All coders need to have an understanding of the requirements of a “compliant” physician query.

The Coder’s Role
The coder is responsible to review the documentation within the medical record to establish the DRG/APC; it is the coder’s responsibility to assure physician documentation, clinical indicators and care provided supports code assignment. With the growing number of documentation improvement programs and concurrent query processes, along with the transition to computer-assisted coding, coders are less likely to be the person to compose the query addressing documentation insufficiencies. Nonetheless, the coder will continue to be the person responsible for assigning the DRG/APC, which means the coder must be able to recognize the elements of a compliant query. Domain VIII, Task 3 — The coder is responsible to recognize and report concerns of noncompliance.

Facility policies and procedures should be in place that defines appropriate documents to review for the purpose of code assignment and defines expectations for query situations regardless of the messenger or means of delivery (e.g., CDS, nurse, coder or verbal/written).

Over the years, the American Health Information Management Association (AHIMA) has released several publications to help plan, implement, and monitor a compliant query process. The AHIMA practice brief, Guidelines for Achieving a Complaint Query Practice released in February 2013, is a continuation and in some instances, a revision of best practice expectations on the physician query as a tool in the documentation improvement process. This practice brief addresses some long debated practices on the how’s, when’s, and what if’s. The following are points of interest on changes or clarifications made in the practice brief, Guidelines for Achieving a Compliant Query Practice.

When to Query
The physician/provider query is a communication tool seeking clarification or additional details from the provider on the patient’s condition and/or treatment that are necessary to support code selection or medical necessity.

The Practice Brief, Guidelines for Achieving a Compliant Query Practice updates the language used to describe when it is appropriate to generate a provider query.
The generation of a query should be considered when the health record documentation:

  • Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
  • Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
  • Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
  • Provides a diagnosis without underlying clinical validation
  • Is unclear for present on admission indicator assignment

A complaint query includes clinical evidence to justify why the query was generated. Glean information from the entire record to compose the query; this includes pertinent diagnostic impressions, treatments, and clinical indicators found in laboratory, radiology and pathology reports, and anesthesia, wound care and nutritional services notes, etc. Although inpatient code selection cannot be assigned based on lab, x-ray and pathology findings, it is acceptable to reference these reports in a provider query.

Construct the query in such a way that it does not lead the physician to document a specific diagnosis or procedure, but presents details from the record to expose inadequate or contradictory documentation that needs further clarification from the provider.

Best practice expectations are that everyone follows compliant query processes, whether the query is verbal or written, delivered by a clinical documentation specialist, or coder. The recommendation is that the content and outcome of both verbal and written queries be recorded and retained. The messenger or delivery method of the query is not nearly as important as the contents of the query. That is not to say there are not compliance requirements specific to query formatting, an inappropriate formatted query can result in claim denial.

“Yes/No” and Multiple-choice Questions
The latest AHIMA practice brief, “Achieving a Compliant Query Practice” clarifies when it is appropriate times to use “Yes/No” queries:

  • Establishing present on admission indicators.
  • Substantiating or further specify a diagnosis that is already present in the health record (e.g., pathology and radiology findings, other diagnostic reports).
  • Clarifying a cause-and-effect relationship between documented conditions such as manifestations/etiology, complications, and conditions/diagnostic findings (e.g., hypertension and congestive heart failure, diabetes and chronic kidney disease).
  • Resolving conflicting documentation from multiple practitioners.

The “yes/no” query is not an acceptable format to introduce a new diagnosis. However, it is acceptable to introduce a new diagnosis as an answer option, along with other clinically appropriate options in a multiple-choice query. To meet compliance requirements relevant clinical indicators and other appropriate documentation must be included in the query content.

Best practice recommendation is that both “yes/no” and multiple choice queries allow space for the provider to add free text and include answer options such as, “clinically undetermined,” “inherent to,” and “not clinical significant.” The term “possible” is recognized as a very broad term and we are discouraged from using it in query composition as a qualifier for uncertain diagnosis.

See Achieving a Compliant Query Practice for query examples.

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Unsupported Diagnosis
In the past, we have been cautioned about questioning the physician’s judgment on a diagnosis that is not supported by the clinical workup. This recommendation has been revised in the practice brief, “Achieving a Compliant Query Practice”, stating it is appropriate to query when there are conflicts between the clinical indicators in the record and a clinically unsupported diagnosis listed by the practitioner. The recommendation is that facilities have an escalation process in place to address these types of issues as well as other query-related concerns such as unanswered queries. Parties involved in the escalation process may be a physician advisor, the chief medical office or other administrative personnel.

The Non-Compliant Query
Domain VII of the CCSP and Domain VIII of the CCS Exam Content Outline, Task 3, Report compliance concerns. The coder is responsible to recognize and report concerns of noncompliance; this includes identifying non-compliant queries that have influenced documentation. It is the coder’s responsibility to report the poorly constructed query as a compliance concern. When code assignment is based on information derived from a non-compliant query, payment can be denied. The reason for the denial will be a coding error due to lack of documentation to support the code selection.

Elements of a Compliant Query
A 12-point checklist on the required elements for a compliant query
1. Query contents pulled from the medical record for the current episode of care
2. When applicable:
a. Present relevant clinical indicators, orders, and/or care provided to support the need for (the query) documentation clarification
b. Detail discrepancies in documentation
c. Provide open-ended queries when possible
d. Apply best practice guidelines to “yes/no” queries
3. Provides free-text space for providers to comment
4. Provides alternate answer options such as “clinically undetermined”, “inherent to”
5. Does not mention reimbursement
6. Does not lead the physician/provider
7. Patient name
8. Admission date and/or date of service
9. Health record number
10. Account number
11. Date query initiated
12. Name and contact information of the individual initiating the query

Compliance is a cornerstone for the coding professional, not only in the query process, but also in all tasks related to code assignment. In preparation for the exam, I recommend you review the links below. These are some earlier AHIMA publications related to facility requirements on the query process.
Finally, I want to conclude with a review of the AHIMA Standards of Ethical Coding.
Best wishes for success on your exam!!

AHIMA Standards of Ethical Coding
Coding professionals should:

  1. Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data.
  2. Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g. reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.
  3. Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.
  4. Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator).
  5. Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.
  6. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines.
  7. Facilitate interdisciplinary collaboration in situations supporting proper coding practices.
  8. Advance coding knowledge and practice through continuing education.
  9. Refuse to participate in or conceal unethical coding or abstraction practices or procedures.
  10. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities ( examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).
  11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

Guideline for Achieving a Complaint Query Practice

Defining the Core Designated Clinical Documentation Set for Coding Compliance

Managing an Effective Query Process

AHIMA Standards of Ethical Coding

Danita Arrowood is an educator/developer for Precyse University ( and an AHIMA Approved ICD 10 CM/PCS Trainer. Arrowood has more than 25 years of coding and auditing experience in both inpatient and outpatient settings. She is currently a reviewer for AHIMA’s Professional Certification Approval Programs and has taught as an adjunct instructor at an AHIMA-approved college in the health information technology associate programs.

1. A provider query can reference abnormal laboratory findings to establish the need for further documentation from the provider.

2. Which option is a noncompliant query?
a. Did the patient have sepsis at the time of admission?
b. Does the patient have aspiration pneumonia?
c. Please clarify if the patient has diabetes type 1 or 2, both are listed in the record
d. Do you agree with the pathology report specifying BPH with seminal vesicle metastasis?

3. Which answer option is not recommended to use in multiple-choice or “yes/no” queries?
a. Clinically undetermined
b. Inherent to
c. Possible
d. Other

1. True
2. B
3. C

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