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Beth Martilik,
MA, RHIA, CDIP, CCS
Assistant Director of Education
AHIMA Approved ICD‑10 Trainer and Ambassador
The key to choosing reasonable options for a query response is to remember that the query must stand alone. Any clinical indicators supporting the options must be included in the query itself. Below are examples of two queries in which the options for response are not reasonable based on clinical indicators used by coder.
Example of Unreasonable Query Options:
| *SOB on admission with BNP 1100 and CXR showing CHF (H&P) *IV Lasix given x 2 days with improvement, continued home dose at discharge (DS) *Final diagnosis CHF exacerbation (DS) Can you clarify the type of CHF being treated? |
The type of CHF is based on evaluation of the right and left ventricular function. Tests that can show this include echocardiogram, MUGA scan, or cardiac catheterization. The measure of the left ventricle’s ability to pump (ejection fraction or EF) can be obtained from these tests. Therefore, a query for the specific type of CHF must include clinical indicators related to ventricular function, otherwise the options would not be reasonable. The coder could add the EF value, or any ventricular dysfunction as part of the clinical indicators. That would make these options for response reasonable and clinically supported.
Example of Unreasonable Query Options:
| *SOB and tachycardia on admission with H&H 5.6/20.4 (H&P) *PRBC x 2 with improvement (DS) Can you specify the type of anemia being treated? |
A reasonable option must be supported by whatever the coder uses as clinical indicators. There is nothing in this query to show that the patient had a history of blood loss. In fact, there is nothing in the clinical indicators to support any specific type of anemia. The coder should add documentation that refers to blood loss, either acute or chronic. If the coder feels the anemia may be related to something else, entries such as recent chemotherapy or malignancy, or use of iron supplementation may also be added. It is vital that any options for response are reasonable and clinically supported by documentation contained in the query itself.
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.
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