The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Integrity Specialists (ACDIS) jointly published a practice brief, aimed at providing guidelines for achieving a compliant query practice in healthcare settings. The Guidelines for Achieving a Compliant Query Practice serve as a crucial resource for coding, Clinical Documentation Improvement (CDI), and other healthcare professionals involved in the query process.
Practice brief’s role in clinical documentation improvement
The primary objective of the practice brief is to establish and support industrywide best practices for the clinical documentation query process. It aims to guide professionals and organizations in developing compliant policies and processes for querying clinical documentation to ensure the validation of clinical documentation within health records and accurate representation of patients' clinical status through proper medical coding. The 2022 practice brief consists of approximately 20 pages, encompassing updated information and changes from the previous 2019 version.
The query process plays a crucial role in various healthcare initiatives, including reimbursement, data stewardship and collection, quality measures, medical necessity, and denial prevention. As such, the guidelines outlined in the practice brief are applicable to all professionals involved in placing physician queries, including external reviewers like the Office of Inspector General and payer review agencies.
The brief outlines when to use "unable to determine" as a query option and emphasizes the importance of avoiding uncertain terms like "possible" and "probable" unless documented by the provider. It stresses the significance of using clinical indicators and evidence from the health record to support the query and to ensure that all queries meet compliance standards, irrespective of how they are generated, such as through artificial intelligence (AI) technology or computer-assisted tools.
The practice brief also addresses the reasons for querying, such as clarifying undocumented diagnoses, resolving conflicting information, identifying the reason for an encounter, and establishing a cause-and-effect relationship. It highlights the need for a careful approach in determining when and whom to query to avoid unnecessary queries or generating queries with insufficient clinical data.
The guidelines further cover the importance of accurate and concise physician queries with relevant multiple-choice options supported by clinical indicators. The practice brief discourages leading queries that might influence the provider's response and stresses the need to maintain compliance and accuracy in the query process.
Organizations must have a process to monitor query compliance, conduct audits, and provide feedback to the query team. The brief emphasizes that responses to queries do not need to be repeated elsewhere in the health record, and verbal queries should be appropriately documented, adhering to organizational policies.
Overall, the practice brief sets forth essential guidelines to ensure compliant query practices and improve clinical documentation integrity, medical coding accuracy, and overall quality of healthcare data. Healthcare professionals and organizations need to follow these guidelines to ensure accurate code assignment and enhance the quality of patient care.
To gain valuable insights into the physician query process, download our white paper, “Achieving Accurate Reimbursements by Maximizing CDI for Physician Queries." Additionally, watch for future posts highlighting five steps for an effective physician query process as well as how to maximize CDI for physician queries for accurate reimbursement.
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