Coders can use these reference sheets for creating relevant and compliant queries. This resource, which serves as an invaluable tool for anyone looking to navigate the complexities of querying, was taken from the HCPro webinar “Comply with Me: A Journey to Compliant Query Practice”, presented by Natalie Negro, MPH, BSN, RN, CCDS, FACHE, the corporate CDI manager at the Hospital of the University of Pennsylvania.
Health information management, Hospital inpatient, Physician queries
The following sample policy regarding query escalation and resolution addresses the specific timing expectations for query responses, how coders should communicate with CDI staff and physician advisors, and what circumstances might warrant raising an unanswered query to the attention of a CDI or HIM manager, physician advisor, or higher-level administrator.
Coders can use this reference sheet to identify common reasons to query for acute myocardial infarctions. It also provides scenarios for each reason. This information was excerpted from information provided by Rhoda Chism, MHL, RN, CCDS, CCS, CPHQ, and Debra Rush, RN, CCDS, during the HCPro webinar, “What the Bleep is Beeping? Getting to the Heart of the Matter: Cardiac Critical Care Review.”
Acid-base disorders are pathologic changes in carbon dioxide partial pressure (pCO2) or serum bicarbonate (HCO3−) that typically produce abnormal arterial pH values.
Acidosis refers to physiologic processes that cause acid accumulation or alkali loss (pH < 7.35)
Alkalosis refers to physiologic processes that cause alkali accumulationor acid loss (pH > 7.45)
Hospital inpatient, Physician queries, Questions and answers
Download the resource below for an expanded Q&A with Natalie Negro, MPH, BSN, RN, CCDS, and Jisha Chacko, MSN, RN, about clinical indicators and querying for aspiration pneumonia.
Auditing and monitoring, Clinical documentation, Health information management, Hospital inpatient, Hospital outpatient, Physician queries
Guidelines for Achieving a Compliant Query Practice was produced through the joint effort of the ACDIS and 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 supersedes one published in 2019 and all previous versions. This resource was originally published on ACDIS.org.
Auditing and monitoring, Clinical documentation, Hospital inpatient, Physician queries
Join Courtney Crozier, MA, RHIA, CCS, CDIP, for this 60-minute webinar as she discusses potentially confusing ICD-10-CM coding guidelines, describes clinical criteria for determining malnutrition severity, and offers strategies for addressing documentation inconsistencies.
