Audrey G. Howard, RHIA, and Cheryl Manchenton, RN, BSN, of 3M Health Information Systems provided this example of a query for a documentation of a case involving a urinary tract infection due to insertion of a Foley catheter.
Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts, and ACDIS Advisory Board member Mark LeBlanc, RN, MBA, CCDS, clinical documentation manager at Hennepin (Missouri) County Medical Center, donated this sample ICD-10-CM sepsis query.
This form represents one example of a possible request for diagnostic clarification/confirmation of diagnosis donated by Paul Evans, RHIA, CCS, CCS-P, CCDS.
This query form is a request for documentation clarification of HIV Status. It was submitted by Paul Evans, RHIA, CCS, CCS-P, supervisor of clinical documentation integrity at Sutter Health in San Francisco. It was originally posted on the Association of Clinical Documentation Improvement Specialists website.
This form can be used to query physicians for additional information for HIV patients. It was submitted by Ameena AbdulMalik of Hermann Memorial Healthcare System in Texas. It was originally published by the Association of Clinical Documentation Improvement Specialists in July.
This form provides a sample query for gastritis, which can be coded to a higher specificity in ICD-10-CM. Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director at HCPro, Inc., in Danvers, Mass., provided the form.
Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director at HCPro, a division of BLR, in Danvers, Massachusetts, provided this sample multiple-choice query for chest pain.
These sample malnutrition queries were donated by Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts, and ACDIS Advisory Board member Mark LeBlanc, RN, MBA, CCDS, clinical documentation manager, at Hennepin (Mo.) County Medical Center, who spoke during the June 10 webinar “Physician Queries: Ensure Effective, Compliant, Regulatory-Based Clarifications.” The queries also appear on the ACDIS website.
The Association for Clinical Documentation Improvement Specialists (ACDIS) surveyed 517 respondents, primarily CDI specialists, about physician queries. The 35-question survey illustrates the importance of the physician query as the primary tool driving CDI efforts, but also demonstrates wide differences regarding query assessment, compliance, and policy review.
