Sleighing the Queries: How to Strengthen Documentation Quality and Reduce Query Volume

Provider documentation is the foundation of accurate coding, compliant billing, and efficient workflows. This guide breaks down the most common reasons queries occur and offers practical tips to strengthen documentation, reduce repetitive clarifications, and support smoother coding and CDI processes. With clearer notes and consistent practices, your team can “sleigh” documentation gaps before they slow down your holiday workload.

When documentation hits turbulence, even Santa’s sleigh can’t stay on course. Clear, complete documentation keeps workflows smooth, reduces delays, and helps coders avoid unnecessary queries all year long.

Why Queries Happen (and Why They Matter)

Queries aren’t a bad thing—they help protect accuracy, support clinical validation, and ensure the record paints a complete clinical picture. But unnecessary or repetitive queries slow everyone down and increase administrative burden.

Most queries fall into a few predictable categories:

• Missing or vague clinical details
• No documented cause-and-effect
• Ambiguous diagnoses
• Incomplete procedure descriptions
• Conflicting documentation across notes
• Lack of linkage between conditions
• Documentation that doesn’t support clinical indicators

When documentation takes a detour, coders can’t help but tap the brakes.

Common Documentation Gaps That Trigger Queries

Lack of Specificity

Providers may document “infection,” “renal failure,” “fracture,” or “heart failure,” but coders need:

• Type
• Acuity
• Laterality
• Etiology
• Stage or severity

Even one missing detail can shift the entire coding pathway.

Missing Relationship Statements

Cause-and-effect is essential for accurate code assignment, particularly for:

• Sepsis and organ dysfunction
• Infections and causative organism
• Substance use and physiological/psychological conditions
• Postoperative complications
• Adverse effects vs expected outcomes of medication usage

Without explicit linkage, coders must query—even when the clinical relationship seems obvious.

Incomplete Procedure Documentation

Procedure notes should include:

• Objective
• Approach
• Method
• Device used
• Laterality
• Location
• Clinically significant findings

Incomplete details are among the top drivers of OR-related queries.

Conflicting Information Across Notes

Documentation details in progress notes, consults, and discharge summaries must align. Queries often arise when:

• Diagnoses differ across documents
• One specialist lists a condition the attending does not
• Discharge summary omits an active condition treated during the stay

Consistency is key.

How to “Sleigh” Queries Before They Begin

Encourage Clear, Complete, Real-Time Documentation

Even small reminders to providers can reduce future queries:

• Document diagnoses as they are confirmed
• Link conditions when clinically appropriate
• Include relevant clinical indicators
• Add procedure detail immediately after surgery
• Verify consistency across all notes

Short, focused education sessions go a long way.

Share Top Query Trends with Providers

Data helps paint a clearer picture. Show providers:

• Their most frequent query types
• Patterns across service lines
• Examples of strong vs. vague documentation
• Quick fixes for recurring issues

This transforms queries from “extra work” into “quality improvement.”

Collaborate with CDI and Coding Teams Year-Round

Open communication ensures:

• Unified messaging to providers
• Shared expectations for documentation standards
• Opportunities for targeted education
• Reduced back-and-forth during audits

When CDI and coding align, documentation improves—and query volume drops.

Use Queries as Education—not Punishment

Reinforce queries as:

• Clinical clarification
• Protection of documentation integrity
• A tool to strengthen patient care continuity

This shifts perceptions and encourages proactive improvement.

A Smoother Flight for Everyone

Better documentation supports more accurate coding, stronger clinical validation, and fewer delays for busy teams—especially during high-volume periods. When providers understand the “why” behind common query types, they’re more likely to document with clarity the first time.

If your teams benefit from consistent education on documentation, coding, or clinical concepts, HIAlearn’s on-demand courses offer practical, concise lessons coders and providers can use immediately.