New Query Process

Query Updates

“Clinical Indicators” is a broad term encompassing documentation that supports a

diagnosis as reportable and/or establishes the presence of a condition. Examples of
clinical indicators include: provider observations (physical exam and assessment),
diagnostic findings, treatments, etc. provided by providers and ancillary
professionals.”

It goes on to state

“The purpose or type of query will impact how much clinical support is necessary to
justify the query….The quality of clinical indicators – how well they relate to the
condition being clarified – is more important than the quantity of clinical indicators
.
Clinical indicators can be identified from sources within the entirety of the patient’s
health record including emergency services, diagnostic findings, and provider
impressions as well as relevant prior visits, if the documentation is clinically pertinent
to the present encounter.”
Query Updates
DETERMINING WHEN TO QUERY

As noted in the AHIMA Guidelines for Achieving a Compliant Query Practice – “Queries
are not necessary for every discrepancy or unaddressed documentation issue. When
determining the need to query, the query professional must consider if the provider
can offer clarification based on the present health record documentation or
resolve/seek clarification on conflicting documentation.”

The generation of a query should be considered when the health record

documentation:

• Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent

• Describes or is associated with clinical indicators without a definitive relationship to
an underlying diagnosis
• Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a
specific condition or procedure
• Provides a diagnosis without underlying clinical validation
• Is unclear for the present on admission indicator assignment.
Query Updates
Determining Who to Query:

• Queries may be generated for any physician active in the care of the patient. This
could involve a surgeon, consultant, attending, hospitalist, ED physician, etc.
Coders and CDI Specialists should use critical thinking along with the medical
record documentation to determine the appropriate provider to query.

• The documentation within the medical record will aid in determining the
appropriate physician to address the query. In general, query the physician
representing the author of the documentation (e.g. consultant, surgeon, etc.) if
there is no conflicting documentation, but physician documentation is not
specific enough to assign the code to the highest level of specificity.

• If there is a conflict within the documentation, the query should be addressed by

the attending physician. Be aware there are operational definitions to ensure the
physician is familiar with the patient’s overall clinical picture and care provided
when determining the attending physician such as PARA.HSC.COD.008. It is
possible that a physician may defer a question to another physician responsible
for the patient’s care with knowledge of the overall clinical picture of the patient.
Query Updates
Appropriate to issue a query regarding a diagnosis or condition which was not
actively treated during a patient’s stay?

• It is not appropriate to issue a query regarding a diagnosis or condition which was

not clinically relevant to the patient’s treatment during the patient’s stay.

• There are circumstances; however, in which a diagnosis or condition other than

the principal one for which the patient sought treatment may be clinically
relevant.

• For example, if there are sufficient clinical indicators in the medical record of a
secondary diagnosis or condition which may affect proper reporting of the
patient’s severity of illness or risk of mortality.

• It may be appropriate to issue a query to the physician even if it is not the primary
diagnosis or condition for which the patient sought treatment. Likewise, if there
are sufficient clinical indicators in the medical record of a secondary diagnosis or
condition which, in the Coder or CDI Specialist’s clinical judgement, may have
been relevant to the physician’s clinical decision-making.
Query Updates
• It is appropriate to issue a query to the physician to resolve whether the secondary
diagnosis or condition was in the physician judgement clinically relevant.

• For example, clinical indications documented in the patient’s history or lab results
may affect the fluids ordered by the physician or the selection or dose of medication
even if those clinical indicators are not directly related to the patient’s principal
diagnosis.

• As noted elsewhere, the Coder or CDI Specialist must utilize their clinical judgment
and ensure that the subject of the query is significant and in context with the
patient’s condition.
Query Updates
The AHIMA/ACDIS 2019 update of the query practice brief states “Queries may be
necessary in (but are not limited to the following instances:

• To support documentation of medical diagnoses or conditions that are clinically

evident and meet Uniform Hospital Discharge Data Set (UHDDS) requirements but
without the corresponding diagnoses or conditions stated
• To resolve conflicting documentation between the attending provider and other
treating providers (whether diagnostic or procedural)
• To clarify the reason for inpatient admission
• To seek clarification when it appears a documented diagnosis is not clinically
supported
• To establish a diagnostic cause-and-effect relationship between medical conditions
• To establish the acuity or specificity of a documented diagnosis to avoid reporting a
default or unspecified code
• To establish the relevance of a condition documented as a “history of” to determine
if the condition is active and not resolved
• To support appropriate Present on Admission (POA) indicator assignment
• To clarify if a diagnosis is ruled in or out
• To clarify the objective and extent of a procedure”
Query Updates
WHEN NOT TO QUERY:

A query should never be generated simply because HCA has a query form and the
patient has two of the clinical indicators listed on the form, unless the clinical picture
of the patient would support the need for clarification.

DO NOT generate a query in the following circumstances:

• The condition/diagnosis in question does not meet UHDDS Reporting Guidelines

(e.g. For reporting purposes the UHDDS definition for "Other diagnoses" is
interpreted as additional conditions that affect patient care in terms of requiring
any of the following: Clinical evaluation; or Therapeutic treatment; or Diagnostic
procedures; or Extended length of hospital stay; or Increased nursing care and/or
monitoring)

• Physician response would result in code J15.6.

• Lack of knowledge (e.g. anatomy, disease process, etc.)

Query Updates
• Physician specifies body part that is not specified in ICD-10-PCS

• Root operation determination for PCS when the correlation between the
documentation and the defined PCS terms are clearly documented

• Diagnosis is documented only one time without conflict but supported clinically
within the medical record

• Documentation of the clinical picture of the patient (e.g. symptoms, diagnostics,

treatment, etc.) DOES NOT support potential conditions (even if there are two
clinical indicators on the standard query form)

• Disease process knowledge explains there is no conflict (e.g. ED documents NSTEMI

but later cardiology documents old NSTEMI with elevated troponins due to CKD)

• Conditions that are clearly ruled out

Query Updates

CLINICAL INDICATORS

It is important to consider the clinical indicators that are being considered for a query
form. Simply having two indicators on a query form does NOT mean the query should
be generated. It is important that they are considered within the clinical context of the
patient. In order to make the determination of when to query, knowledge of coding
concepts, coding guidelines as well as clinical knowledge (such as Anatomy, Physiology,
Pathophysiology, pharmacology, terminology, etc.) are equally as important.
Query Updates
Scenario Example for Clinical Indicators:
75-year-old patient with altered mental status, labored breathing, hypoxia,
uncontrolled type I diabetes, dizziness and hypotension admitted for observation due
to dehydration due to gastroenteritis. While in the facility diagnostic work up included
labs, table test, and the patient received IV fluids, antibiotics, and monitor/control of
sugar. The final diagnoses included dehydration and food poisoning/diarrhea as the
cause for their symptoms which included confusion, hypoxia, hypotension when
vomiting. The dizziness is due to benign paroxysmal positional vertigo and possibly the
dehydration.
In this example, it is possible to check off two clinical indicators on three different HCA
query forms.
• The Blood Status Query Form has clinical indicators of dizzy and hypotension along
with chronic condition of diabetes; however there is no other information in the
record to support querying for any blood disorder such as anemia. These symptoms
support the clinical picture of the patient with dizziness and hypotension from the
nausea and vomiting.
Query Updates

• The Respiratory Status Query Form has clinical indicators of hypoxia and labored
breathing; however, there is no other information to support any respiratory status
disorder such as respiratory failure. These symptoms support the clinical picture of
the patient with hypoxia and labored breathing which are associated with nausea
and vomiting.
• The Infectious Status Query Form has clinical indicators of hypotension and altered
mental status. There is no clinical information in this record to support an infectious
condition that is not already documented. The clinical picture of the patient
supports the food poisoning and diarrhea.

Therefore, it would not be appropriate to generate a query with this scenario using the
Blood Status, Respiratory Status or Infectious Status query form even though there are
two clinical indicators that are included on the three unique query forms.
Query Updates

DIAGNOSIS DOCUMENTED ONCE:

If the diagnosis is documented only once, does the diagnosis require a query? The
answer is not a simple yes or no as one must utilize critical thinking skills,
knowledge of disease process, and knowledge of UHDDS Guidance for reportable
diagnoses. Clinical expertise and coding guideline and conventions knowledge is
also crucial.

Unfortunately, the only answer to this question is sometimes but not always. The
Uniform Hospital Discharge Data Set defines “other diagnoses” as “All conditions
that coexist at the time of admission, that develop subsequently or that affect the
treatment received and/or length of stay. Diagnoses that relate to an earlier
episode which have no bearing on the current hospital stay are to be excluded”.
Query Updates
Coding guidelines define “other diagnoses” as additional conditions that affect
patient care because they require one or more of the following: Clinical
Evaluation, Therapeutic treatment, Diagnostic Procedures, Extended length of
stay, increased nursing care and/or monitoring.

Lastly the clinical picture of the patient must be considered utilizing clinical
judgement and knowledge of disease process involving clinical terminology,
pharmacology, pathophysiology as well as anatomy & physiology.

When considering the single documented diagnosis, one must consider – Does
the documentation support assignment of the diagnosis in accordance with all
of these reporting guidelines? If the answer is yes, the condition may
potentially be coded unless there is a need to query for further specify of the
condition.
Query Updates

Scenario Example for Diagnosis Documented Once:

The example involves a patient in which the ED physician is the only one to document
hyponatremia on a 4-day LOS. The patient received IV sodium in ED and diuretics
with monitoring the entire stay for their exacerbation of CHF with swelling of lower
extremities that resolved on the day of discharge. The sodium level on admission was
128 and redrawn showing 136 the next day. The hospitalist’s progress notes only
document the CHF. The question – Can the documentation support hyponatremia or
is a query required because it is documented only once? In this case, no query is
required as the documentation supports the hyponatremia when critical thinking
skills using coding guidance, clinical judgment and UHDDS definitions are applied.
Query Updates

First consider the element of clinical judgement and utilizing clinical terminology,
pathophysiology and pharmacology. The diagnosis of hyponatremia is supported
and not conflicting in the medical record. A low sodium level equates to the clinical
term “hyponatremia”. Pathophysiology provides insight into the disease process to
recognize that sodium plays a key role in maintaining normal blood pressure,
supporting the work of nerves and muscles and regulating fluid balance in our
bodies. The normal level is between 135-145 and hyponatremia occurs when
sodium in blood falls below 135. Considering the pathophysiology impact of
congestive heart failure is also important as this condition can impact kidneys or liver
and cause fluids to accumulate in the body which dilutes the sodium resulting in
lowering the overall level. Lastly, the treatment for hyponatremia tends to include
items such as monitoring intake/output, IV fluids with sodium solution and
managing medications such as diuretics with pharmacology understanding.
Query Updates
Next, consider whether or not this condition meets the UHDDS reporting
definition. The answer again is yes. Hyponatremia did coexist at the time of
admission when the patient presented to the emergency room. The diagnosis as
previously discussed did affect the treatment of the patient.

The third consideration involves the coding guidance for hyponatremia. From a
reporting standpoint, there is clinical evaluation of the condition with the ED
physician’s assessment of the diagnosis. There is therapeutic treatment with the IV
sodium and lastly there is diagnostic procedures with the two lab values. There are
no coding guidelines that require any additional specificity for the diagnosis of
hyponatremia and the acuity and type of congestive heart failure has been clearly
documented by the hospitalist.
Query Updates
USE OF ENTIRE MEDICAL RECORD:
It is important that the entire medical record be utilized when determining if a query
is necessary.

Scenario Examples for Use of Entire medical Record:

A patient admitted through the ED with the diagnosis of cellulitis, hyponatremia,

leukocytosis and sepsis. The lab work shows white cell count of 11.9, lactic acid 1.5
while the physical exam shows pulse of 131 and temperature of 38.9. It is important to
understand normal values to determine the value of the documentation. With the
documentation provided so far, the pulse is elevated as is the temperature and white
cell count. The lactic acid is borderline normal almost high. Unfortunately, the
diagnosis provided by the ED physician of sepsis wasn’t documented any further by
the hospitalists as they only documented cellulitis and hyponatremia. Coding and CDI
is faced with determining what happened with the disappearing diagnosis of sepsis.
Was it ruled out? Is it supported with other documentation which would allow it to be
coded even though only mentioned once? Is it questionable that it may be supported
and would require a query based on the clinical indicators in record?
Query Updates
The documentation includes two clinical indicators and sepsis documented once by
ED and not by any other physician involved in the patient’s care after the initial arrival
to the hospital. Unfortunately we do not have information such as what diagnostics
were performed, how the patient was treated or the status of the patient at discharge
for the outcome of the treatment. Therefore, there is not enough information here to
know if a query is warranted. More information from the medical record is needed.

As a summary, the clinical documentation we have so far includes the indicators

noted below, which we will consider with two different patient’s records – Patient B
and Patient A to determine if a query is necessary once the entire medical record is
considered.

• Elevated WBCs
• Elevated Pulse
• Respiratory rate upper end of normal
• Elevated Lactic Acid
• Elevated Temperature
• Dx: Cellulitis, Hyponatremia, Leukocytosis with Sepsis documented in ED one time
Query Updates
Patient B – Additional Documentation includes the following:
• 2 Day LOS
• Non-excisional Debridement
• IV Hydration
• Oral Antibiotic (Cefazolin)
• Sepsis not documented any time again in the hospital stay with subsequent labs
showing normal
The review of remaining record for the patient who is admitted with cellulitis, and
slightly elevated white cells and temperature provides additional information. The
patient was in the facility for two days with IV fluids and an oral antibiotic for the
cellulitis that required nonexcisional debridement. The patient received IV hydration
and the hyponatremia resolved. Subsequent lab values showed normal WBCs and
lactic acid. The fever subsided within a few hours of arrival. The sepsis was clearly
entertained by the ED initially, but upon further exam and treatment, there is no
additional information to support that the patient was ill enough to be septic.
The additional information in each scenario helps paint the complete clinical picture
of the patient for determination on when to query and when not to query. For
patient B, a query would not be generated.
Query Updates
Patient A – Additional Documentation includes the following:
• 5 Day LOS
• Non-Excisional Debridement
• IV Hydration
• IV Antibiotic (Rocephin)
• Sepsis not documented any time again in the hospital stay but subsequent labs
showed decrease in WBCs
• Infectious Disease Consult

To demonstrate fully how the additional information impacts the query consider
the same basic information with different additional documentation in the medical
record.
Query Updates
Patient A has the same basic information as Patient B which includes the following:
ED documenting cellulitis, hyponatremia, leukocytosis and sepsis. Lab shows WBCs
at 11.9, Pulse at 131, Lactic acid at 1.6, temperature of 38.9. All of the Hospitalist’s
progress notes specify cellulitis and hyponatremia.

On the query path with Patient A, the additional information specified

demonstrates a longer stay in the facility of five days with the nonexcisional
debridement and hydration. Infectious Disease was brought onto the case at the
time of admission, but they didn’t list a diagnosis in their notes. Infectious disease
put the patient on IV Rocephin and multiple subsequent labs were drawn until the
WBCs demonstrated normal values.

With this additional information a query would be warranted as the ED has noted
sepsis but it’s unclear if the patient truly has sepsis; however, there are clinical
indicators that suggest there is some infectious process since they were in the
hospital longer, drew more labs, involved consult with infectious disease and
required IV antibiotics. A query would be generated for patient A.
Query Updates: Application

3M 360 Encompass

• it is important to note that all of the guidelines included in the query handbook
apply to the query forms generated regardless of the system for which it was
generated. refer to individual chapters for specifics on guidelines for each query
form.

• The naming conventions within 3M 360 are unique and are similar but not always
the same as our existing HCA queries. The table below provides a mapping of the
3M 360 Query to HCA Standard Query Forms.
Query Updates: Application

HIGHLIGHTS OF 3M 360 QUERIES

With this section we will highlight items unique to 3M 360 queries especially compared
to our highest system of query use involving HPF/FormsFast. Queries may be
generated by the CDI Specialist/Coder which are referred to as manual queries. There
are also some queries that are generated by the system which are referred to as
automated queries. The highlighted items appear on both automated and manual
queries.

• Many query forms have standard clinical indicators. Instead of a list of clinical
indicators for the CDI Specialist/Coder to check off those that apply, only the clinical
indicators that apply to the specific patient are copied/pasted into the clinical
indicator section of the query form. For example, a query form may have 12
possible clinical indicators and only 4 apply for that patient. Only these four would
be copied and pasted into the query form template that would display for the
physician
Query Updates: Application

• Physicians are provided reasonable options on most query forms in the form of check
off boxes. The physician may check off their responses as well as provide free text. It
is appropriate to utilize for coding when properly authenticated by the physician.

• Based on the physician’s response, some queries will generate a secondary question
to the physician.

• Some query forms provide the option to display reference material.

• Query templates will include some programming language that the Coder/CDI
Specialist can view but that is not visible to the physician when answering the query.
It is important to not alter that programming language since it impacts the display of
the query.

• Query templates do have some areas in single brackets with instructions to insert
documentation such as “[Insert source document(s) and date(s)]” that is completed
by the Coder/CDI Specialist.
Query Updates: Application
• The instruction language that noted the two clinical indicators are required prior to
using the “other” clinical indicator field guideline still applies even though it is not
visible on the form.

• There is limited space for the query to display for the physician; however the query
does scroll so the entire query and reasonable options are visible to the physician.

• If the physician selects clinically unable to determine, a secondary question will

appear asking for explanation.

• There are some additional query templates in 3M360 that are not within HPF/MPF
or paper query form; however, a mapping has been included for the query forms
due to the functionality of the 3M360 query template. For example, additional
general query forms were generated such as “Condition General”, “Relationship
Diagnosis General”, “Clarification Diagnostic Test”.
Query Updates: Application

REPORTING/DASHBOARD

Reporting within CAC has multiple options which are within the Parallon 3M360
Reference Manual. There are numerous reports with multiple options for specifying
data within the report. Dashboards entitled Corporate Summary Query Dashboard
and Corporate Summary CAC Query Dashboard. These dashboards are available for
those with access at the following links and allow HSC query reporting for CAC and
Non CAC (i.e. Meditech, Cerner, etc.) queries. (See examples in reporting chapter)
Query Updates: Application
UNIQUE 3M 360 QUERIES

With this section we will highlight queries unique to 3M 360 queries. These queries
were created based on need and system capability. They are as follows:
• Clarification Diagnostic Test – This query form is utilized to seek clarification and/or
clinical significance of any diagnostic test. For example, if a patient had a low
sodium level with IV NA, this query may be generated. Within HPF, this type of
query would have been generated with the general query form. This query form is
not utilized for pathology which have their own unique query.
• Relationship Diagnosis General – This query form is utilized to determine the
relationship between diagnoses. It can assist in determining underlying causes.
Within HPF, this type of query would have been generated with the general query
form. This query form is not utilized for determining the relationship with
procedures which have their own unique query form (i.e. Relationship Procedure
Condition Query).
Query Updates: Application

• Procedure Specificity General – This query form is utilized to determine further

specificity for a procedure. It is important to use this form within AHIMA Guidelines
for Achieving a Compliant ICD-10-PCS Query. For example, a query is not generated
due to lack of knowledge of if body part is specified but not specified in PCS. An
example of procedure query generation may be to determine which vein when not
specified such as if the physician documents saphenous vein was harvested and PCS
requires knowing if it was greater or lesser saphenous vein. With HPF, this query
would have been generated with the general or specificity query form.
Query Updates: Application

SAMPLE QUERY FORMS

The sample that is displayed is for the Acuity of Heart Failure. The example
demonstrates what those visualize when creating the query as well as what is visible
when answering a query. Keep in mind every query form template is unique and may
not include reasonable options. Some have more free text than others. An example of
the “printed” final query is also provided that would be part of the permanent medical
record.

This first example shows the window to create the acuity heart failure query for CDI
Specialist/Coder.
Query Updates: Application
Query Updates: Application

The second example shows the same query as it is being created by the CDI
Specialist/Coder that shows the programming language. The terms in the double
brackets show the responses that the physician will be presented in the drop down
boxes that are unique for this query form.
Query Updates: Application
The third example shows the same query as it would appear to the physician with
reasonable options for responses. (Note the print screen is cut off and the clinical
indicators would display to the physician that were entered) The physician has the
option to check any of the boxes for heart failure acuity or respond and create a new
note. There are a few other options such as clinically unable to determine that could
be selected as well that are visible with scrolling in the product.
Query Updates: Application

For example – scrolling after respond – Create new note now will display the rest of
the options
Query Updates: Application

Question on Query updates related to 3M 360:

▪ Will CDI and Coding use 3M 360 to generate queries?

▪ Are there query forms within 3M 360 that do not exist with HCA’s paper query or
within HPF?

▪ The 3M query form appears differently than the paper and HPF version of query
Nutritional Status Query Form. Why the revision to the form in this version?

▪ Is 3M 360 the only CAC used within HCA?

▪ Is there a naming convention for the 3M 360 query forms?

Query Updates: Application

Answers on Query updates related to 3M 360:

• Will CDI and Coding use 3M 360 to generate queries?

Yes, both CDI Specialists and Coding will use 3M 360 to generate queries. The
system facilitates concurrent and retrospective manual queries

• Are there query forms within 3M 360 that do not exist with HCA’s paper query or
within HPF?
Yes, 3M 360 has automated and manual queries. The automated queries are
unique to the 3M product. The manual queries mimic as closely as possible the
HCA standard query forms. There are some additional queries due to the abilities
of the system. Specifically, 3M 360 has the following manual query forms that are
unique: Relationship Diagnoses General, Procedure Specificity, and Clarification
Diagnostic Test. There is map for the HCA Standard Query Forms and HCA 3M
360 Query Forms. Basically, we added unique query form and responses to
capture common general query form questions to determine the relationship
between diagnoses as well as determining conditions for diagnostic findings.
Query Updates: Application
▪ The 3M query form appears differently than the paper and HPF version of query
Nutritional Status Query Form. Why the revision to the form in this version?
The form was revised in an attempt to ensure the physician provides clinical
context to support the diagnosis based on feedback received from external
reviews. It is not a departure from existing information on the paper which is
based on ASPEN guidance. It simply has an open format. The clinical indicators
included on the current query form, all still apply and can be used on the query
form.

• Is 3M 360 the only CAC used within HCA?

No, Optum CAC is in place at limited facilities prior to HCA acquisition.

• Is there a naming convention for the 3M 360 query forms?

Yes. Queries that start with Relationship are to determine the relationship
within the question. Those that begin with specificity are seeking further
specificity for a documented diagnosis. Those that begin with clarification or
condition are seeking to determine a diagnosis. There are some names that are
very close to HCA name such as POA, Type HF, Acuity HF, Stage CKD, Type
Debridement, Depth Debridement, etc.
Query Updates: Forms
• Pneumonia with positive sputum cultures Query Form (Deployed 2001, Replaced
2010)
• Pneumonia Query Form #4 (Formerly Known as Aspiration Pneumonia; Deployed
2001, Revised 2010, Revised 2011, Revised 2013, Revised 2015, Revised 2016)
• Sepsis with positive blood cultures Query Form (Deployed 2001, Replaced 2010)
• Infectious Status Query Form #13 (Formerly Known as Generalized Sepsis-
Deployed 2001, Revised 2010, Revised 2011, Revised 2013, Revised 2015, Revised
2016, Revised 2017)
• Infectious Status POA Query Form #36 (Deployed 2017)
• Urosepsis Query Form #20 (Deployed 2001, Revised 2010, Revised 2011, Revised
2013, Revised 2015, Revised 2016, Revised 2017)
• General Query Form # 11 (Deployed 2001, Revised 2010, Revised 2011, Revised
2013, Revised 2015, Revised 2016 )
• Blood Condition Query Form#1 (Formerly known as Anemia - Deployed 2006,
Revised 2010, Revised 2011, Revised 2013, Revised 2015)
• Septicemia with Positive Blood Cultures Query Form (Deployed 2006, Replaced
2010)
• Diagnosis Occasioning the Admission Query Form #10 (Deployed 2006, Revised
2010, Revised 2011, Revised 2013, Revised 2015)
Query Updates: Forms
• Angina Pectoris Query Form #3 (2007 Deployment; 2010 Revision, Revised 2011,
Revised 2013, Retired 2015 )
• Heart Failure Query Form#14 (2007 Deployment; 2010 Revision, Revised 2011,
Revised 2013, Revised 2015, Revised 2016, Revised 2017 )
• Heart Failure Acuity Query Form #27 (Deployed 2015, Revised 2016, Revised 2017
)
• Heart Failure Type Query Form #28 (Deployed 2015, Revised 2016, Revised 2017 )
• Chronic Obstructive Pulmonary Disease Query Form#6 (2007 Deployment;
2010Revision, Revised 2011, Revised 2013, Retired 2015)
• Nutritional Status Query Form#16 (Formerly known as Malnutrition - 2007
Deployment; 2010 Revision, Revised 2011, Revised 2013, Revised 2015, Revised
2016)
• Present on Admission POA Query Form #18 (Formerly known as Assignment of
Present on Admission (POA) Indicator; 2007 Deployment; 2010 Revision, Revised
2011, Revised 2013, Revised 2015, Revised 2016)
• Renal Status Query Form #2 (Formerly known as Acute Renal Failure - Deployed
2008; 2010 Revision, Revised 2011, Revised 2013, Revised 2015, Revised 2016)
• Chronic Kidney Disease Staging Query Form #5 (Deployed 2008; 2010 Revision,
Revised 2011, Revised 2013, Revised 2015, Revised 2016)
Query Updates: Forms
• Atelectasis/Pleural Effusion Query Form(Deployed 2008; Retired 2010)
• Respiratory Status Query Form #19 (Formerly known as Respiratory Failure -
Deployed 2008; 2010 Revision, Revised 2011, Revised 2013, Revised 2015)
• Acute Myocardial Infarction Query Form (Deployed 2008; Retired 2010)
• Cardiac Arrhythmia Query Form (Deployed 2008; Retired 2010)
• Cardiogenic Shock Query Form (Deployed 2008; Retired 2010)
• Cerebrovascular Accident Query Form #7 (Deployed 2008; 2010 Revision, Revised
2011, Revised 2013, Retired 2015 )
• Decubitus/Pressure Ulcer Query Form #9 (Deployed 2008; 2010 Revision, Revised
2011, Revised 2013, Retired 2015)
• Inpatient Wound Proc Query Form # 8 (Formerly known as Inpatient Debridement
- Deployed 2009; 2010 Revision, Revised 2011, Revised 2013, Revised 2015,
Revised 2017 )
• Organism Clarif Query Form #15 (Formerly known as Infectious Organism -
Deployed 2010, Revised 2011, Revised 2013, Revised 2015, Revised 2017)
• Specificity Query Form #12(Deployed 2010, Revised 2011, Revised 2013, Revised
2015, Revised 2016)
• Pathology Finding Query Form #17 (Deployed 2010, Revised 2011, Revised 2013,
Revised 2015, Revised 2016)
Query Updates: Forms
• Gustilo Open Fx Query Form #23 (Deployed 2015, Revised 2016)
• Fractures Clarif Query Form #24 (Deployed 2015)
• Skin Integrity Query Form #25 (Deployed 2015, Revised 2017)
• Asthma Clarification Query Form #26 (Deployed 2015, Revised 2016)
• Conflicting Dx or Px Query Form #29 (Deployed 2015)
• Rule in/Rule Out Query Form #30 (Deployed 2015, Revised 2016)
• Intra/Post Procedure Condition Query Form#31 (Deployed 2015), Revised 2017
• Diabetes Query Form #32 (Deployed 2015, Revised 2016)
• Sepsis Clarification Query #33 (Deployed 2016, Revised 2017)
• Debridement Type Query #34 (Deployed 2016, Revised 2017)

Our standard query forms that are disease or procedure in nature are mostly multiple
choice query formats. “Multiple choice query formats should include clinically
significant and reasonable options as supported by clinical indicators in the health
record, recognizing that there may be only one reasonable option. As such, providing a
new diagnosis as an option in a multiple choice list – as supported and substantiated by
referenced clinical indicators from the health record – is not introducing new
information.” It goes on further to clarify that it should always include an “other”
option.
Query Updates: Maintenance
Query Form Maintenance

• All responses to the query is maintained on the medical record for subsequent
coding reviews/audits/future referencing as supporting documentation that a
query was initiated to clarify incomplete, ambiguous, or conflicting
documentation.

• It is important to remember that any query (concurrent, retrospective, and/or

post initial billing) may be posed verbally or in writing. The query (whether verbal
or in writing) must be documented on one of the approved and required
standardized query forms and maintained in the body of the medical record. The
facility must ensure that the reimbursement received by the facility is appropriate
based upon acceptable medical record documentation.
Concurrent query process
The query process can be conducted and documented on a concurrent (pre-
discharge), retrospective (post-discharge) or post-initial billing basis. A concurrent
query is defined as one that is initiated before the patient has been discharged from
the facility to clarify documentation for the purpose of ensuring a complete and
accurate medical record and for final code assignment.
Query Updates: Maintenance
Unanswered Concurrent Queries
Any unanswered concurrent queries at the time of the patient’s discharge will be
incorporated into the facility’s retrospective query process. The unanswered concurrent
query will be maintained on the medical record.
• If the question remains the same retrospectively as it was concurrently, coding no
longer reissues the CDI query. The Coder may update the date and contact on the
query form and incorporate the unanswered concurrent query as a retrospective
query.
• If the question changes (e.g. different form, different question, additional clinical
indicators, etc.), the Coder must generate a new retrospective query form.
• If the unanswered concurrent query is determined to be invalid or unnecessary, the
query will be retired as outlined in PARA.HSC.COD.20 – Physician Query Form
Maintenance Policy.
• HPF coding workflow is in place to route concurrent FormFast and Meditech pDoc
queries to the Coding Priority Queue when the physician responds to the query.
• Automated workflow does not exist for scanned concurrent queries. Manual routing
is required upon completion of the query.
• Any compliance concerns with the concurrent query must be discussed on a regular
basis between the CDI Specialists and the Coder and/or HSC Designee.
Query Updates: Forms
Retrospective Query Process

• A retrospective coding query is defined as one that is initiated after the patient
has been discharged from the facility, but before the claim has been billed. A
retrospective query is generated by the Coder.

• The query can be written or verbal but must be noted on one of the approved
standardized physician query forms and maintained in the body of the medical
record. The facility must ensure that the reimbursement received by the facility is
appropriate based upon the acceptable medical record documentation.

• Any chart awaiting a query response should not be final abstracted (final billed)
until the physician’s response is documented in the body of the medical record
(either on the query form or in the traditional medical record as appropriate) or
the physician has responded that no addition or clarification to the medical record
is necessary.
Query Updates: Forms
Post Initial Billing Query Process

• The post initial billing query is defined as a query that is executed as a result of
additional documentation (e.g., discharge summary) being added to the record or
findings during a retrospective coding review (internal or external) that occurs after
the bill has been dropped. Query initiation for post initial billing can only occur
within 12 months of the discharge date.

• The physician’s response to the query must be obtained within two weeks (14
calendar days) of the query initiation and must also be within 12 months of the
discharge date. If the physician’s response to the post initial billing query generated
is not obtained within two weeks (14 calendar days), the query is neither
considered nor acceptable for supporting the code/MS-DRG assignment. If a chart
needing the post initial billing query is beyond 12 months from the discharge date,
a query should not be initiated.

• When the physician’s response dictates a rebill, the process must be initiated
promptly following the Company’s rebilling guidelines. Overpayments shall be
refunded within 30 days of the confirmation.
Query Updates: Forms
Query Updates: Forms
Thank You