AHIMA Toolkit Walks CDI And Coding Professionals Through The Querying Process

Queries becoming a common practice in ensuring correct, complete documentation

As documentation practices by providers continue to vary, querying has become a common, educational method to ensure that clinical information is compliant.

A query is the process by which questions are posed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record. Having a query process benefits hospitals’ compliance with billing and coding rules, and serves as an educational tool for providers, clinical documentation improvement (CDI) professionals and coding professionals.

The American Health Information Management (AHIMA) Query Toolkit offers the necessary guidelines for successful querying, including templates to guide organizations and professionals in developing their query process.

“Medical staffs should be informed of the need and the procedure for creating effective queries in order to promote complete and accurate documentation,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA. “This new AHIMA toolkit provides an in-depth solution, providing resources on when to write a query and the step-by-step process of what it entails.”

One main challenge for CDI and coding professionals is knowing when a query is needed. The AHIMA toolkit suggests queries should be initiated when information appears to be missing, including the diagnosis or condition, or other details. Additionally, it may be appropriate to generate a provider query when documentation fails to meet logistical criteria such as legibility, consistency, timeliness, etc. Queries should also be used to achieve complete health record entries or entries that address areas such as the clinical significance of abnormal test results, changes in the patient’s condition or co-existing conditions and diagnostic and therapeutic procedures provided.

The toolkit includes both a general template for queries, addressing the basic need to clarify clinical information, and specific query templates that address:

• Infectious and parasitic diseases
• Cancer diagnoses and clarifications
• Endocrine, nutritional and metabolic diseases
• Mental, behavioral and neurodevelopmental disorders
• Pregnancy and childbirth
• Diseases of the nervous, circulatory, respiratory, digestive and genitourinary systems

The toolkit is free for AHIMA members and can be found online in AHIMA’s HIM Body of Knowledge and on AHIMA’s web store (https://my.ahima.org/store/product?id=64472).

About AHIMA
The American Health Information Management Association (AHIMA) represents more than 103,000 health information professionals in the United States and around the world. AHIMA is committed to promoting and advocating for high quality research, best practices and effective standards in health information and to actively contributing to the development and advancement of health information professionals worldwide. AHIMA’s enduring goal is quality healthcare through quality information. For more information, visit www.ahima.org.