Physician queries

This query form is a request for documentation clarification of pathology findings. It was submitted by Paul Evans, RHIA, CCS, CCS-P, supervisor of clinical documentation integrity at Sutter Health in San Francisco. It originally appeared on the Association for Clinical Documentation Specialists website.

Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro 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 alcohol dependence query.

These sample ICD-10-CM queries address establishing the relationship between conditions in ICD-10 t. These queries are adapted from The CDI Specialist’s Guide to ICD-10, created and donated by Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA approved ICD-10-CM/PCS trainer, CDI education director at HCPro, Inc., in Danvers, Mass.

Karen Bridgeman, MSN, RN, clinical documentation integrity specialist at the Medical University of South Carolina in Charleston, donated these case examples and sample queries for pediatric hypoxic ischemic encephalopathy, following her ACDIS National Conference presentation "Leap Frog to Pediatrics: Implementing a Successful Pediatric CDI Program.” They originally appeared on the ACDIS website.

Karen Bridgeman, MSN, RN, clinical documentation integrity specialist at the Medical University of South Carolina in Charleston, donated this case example and sample query for pediatric bronchopulmonary dysplasia, following her ACDIS National Conference presentation "Leap Frog to Pediatrics: Implementing a Successful Pediatric CDI Program.” They originally appeared on the ACDIS website.

>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 respiratory failure query.