It’s OK to ask direct (but not leading) queries to the provider, CDI professionals

By Brian Murphy

Ask direct queries. It’s OK.

Sometimes we get so fixated on query format we fail to see forest through the trees.

The point of a query is to ask a pointed, clinically relevant question and allow the physician to exercise his/her independent judgement.

We should be asking direct no-nonsense queries, especially in the outpatient setting when chronic disease treatment and YOY RAF capture are the principal goals. There is ample support from the existing ACDIS/AHIMA query guidance to support it.

Per ACDIS/AHIMA, you can’t ask a yes/no question to obtain a new or undocumented diagnosis or condition … but you can certainly ask a yes/no question to clarify an existing one.

The brief specifically states “substantiating a diagnosis that is present within the current medical record” with a yes/no query is permissible.

If a query like this feels too directive, well, how else should it be directed? The question must be asked. Just include where the question is derived. This can be from prior records. The 2022 AHIMA-ACDIS Compliant Clinical Documentation Integrity Technology Standards paper says the question can for example derive from an ongoing treatment plan, if an organizational policy allows it.

“Additionally, a query may be generated based on a provider’s treatment plan as long as it is authenticated, unless the organization’s policies and procedures prohibit this process.”

Just cite your work.

The query brief stresses concision. It states that one should remove answer options that are not clinically credible or relevant from multiple choice queries, and there may only be one valid option. Per the brief:

“Multiple-choice query formats should include clinically significant and reasonable option(s) as supported by clinical indicator(s) in the health record, recognizing that occasionally there may be only one reasonable option.”

CDI professionals should never feel like they have to ask terrible, non-clinical questions with a long list of options for the sake of “compliance.” That practice loses credibility, fast.

The guidelines state it is inappropriate to “mine” a previous encounter to generate queries not related to the current encounter. But of course, ongoing chronic conditions managed in the OP encounter almost certainly will always be related to why the patient is in the office. Any medical record should have the patient’s medications listed, which meets the query brief requirement: “A query cannot be based solely on the information from a prior encounter, there must be relevant information within the current encounter to substantiate the query.”

TL;DR version. Do not document on behalf of the physician. Allow him or her to exercise their independent clinical judgement. But asking them a direct question to confirm whether a prior chronic condition is still clinically relevant? That’s good CDI practice. Have at it.

Note: Separate OP query guidance exists (see below), although it’s from 2018 and the 2022 guidance supersedes. But it does contain an example of a direct question about prior diagnoses based solely on PMH and ongoing treatment, and concludes by asking the provider to redocument them:

Your patient, Mr. Jones, has a past medical history of CAD, CHF, and COPD, as noted on his previous office visit. Current medications include albuterol, nitroglycerin PRN, and Lasix. Please review this encounter and these conditions for relevancy and document within Mr. Jones’ upcoming appointment if these are still relevant, and please provide clinical support of how they are affecting his care and/or if these conditions are being managed.

It is also worth noting Section IV of the Official Guidelines for Coding and Reporting, “Chronic diseases,” which states, “Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).”

References

• Guidelines for Achieving a Compliant Query Practice—2022 Update: https://acdis.org/resources/guidelines-achieving-compliant-query-practice%E2%80%942022-update
• ACDIS 2026 Pocket Guide
• ACDIS/AHIMA compliant clinical documentation integrity technology standards: https://acdis.org/resources/acdisahima-compliant-clinical-documentation-integrity-technology-standards
• Queries in outpatient CDI: Developing a compliant, effective process: https://acdis.org/resources/queries-outpatient-cdi-developing-compliant-effective-process