All queries require at least two elements – clinical indicators and a query question. Coders can also include multiple choice options for response or leave the query open-ended for a free text response. The order in which these elements are listed in a query is open to coder or facility preference. The AHIMA Practice Brief “ Guidelines for Achieving a Compliant Query Practice” gives examples using two basic formats – one with clinical indicators followed by the question and options ( Example #1), and another with the question and options listed first, followed by the clinical indicators ( Example #2). The key is to be consistent in how the query is formatted. Each element should be clearly defined for ease of reading. Coders may make use of bold text, underlining, spacing or other methods to ensure that the query is easy to follow, and all elements are present.
Query Format Example #1:
| CLINICAL INDICATORS: (HP) Admitted w/ acute exacerbation of CHF (Echo) EF 35% (DS) Treated w/ IV Lasix with improvement
Can you specify the type of CHF? |
Query Format Example #2:
| Can you specify the type of CHF? *Acute exacerbation of diastolic CHF *Acute exacerbation of systolic CHF *Acute exacerbation of diastolic and systolic CHF *Other type (specify) __________ *Unable to determine
CLINICAL INDICATORS: |
The information contained in this query advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.