“Guidelines for Achieving a Compliant Query Practice” was produced through the joint effort of the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA). Both associations collaborated on the creation of this practice brief and approved its contents, and as such it represents the recommended industry standard for provider queries.
This practice brief supercedes one published in 2016 and all previous versions.
The following is an excerpt from The Coder’s Guide to Physician Queries byAdrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP,with contributions from Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACH. Chapter 2, “Understanding the Regulatory Environment,” provides valuable information for coders ongovernment payer initiatives to ensure ethical query submissions.
Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of regional clinical documentation and coding integrity at SutterHealth in San Francisco, California, offers this sample heart failure query form which includes educational definitions of heart failure, cardiomyopathy and other related concerns. This query originally appeared on the ACDIS website.
This sample flow chart from ACDIS illustrates the physician query process from initial query submission through to resolution. Lynne Spryszak, RN, CCDS, CPC-A, CDI education director at HCPro, a division of BLR, in Middleton MA, included this chart in the audio conference presentation "Physician Queries Workshop: Tools and Techniques for Compliant, Effective Clarification."
Robert Hodges, BSN, MSN RN, CCDS, and clinical documentation improvement specialist at the Aleda E. Lutz VA Medical Center in Saginaw, Michigan, donated this sample malnutrition query to ACDIS.
Rebecca A. “Ali” Williams, RN, BSN, CCDS, manager of documentation integrity at Spartanburg Regional Medical Center and Village at Pelham Hospital in Spartanburg, S.C., shared this sample query for a subarachnoid bleed in ICD-10-CM.
