Query Tip: Query for Clinical Validation

Apr 26, 2019

When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, a coder has four choices:
  • Code the diagnosis
  • Ignore the diagnosis
  • Generate a query to confirm clinical validation of a diagnosis
  • Follow the facility’s escalation policy for clinical validation

Two recent Coding Clinics address the first two options: Coding Clinic, Fourth Quarter 2016: Page 147 and Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Page 110.

A coder may be asked to send a physician query to obtain the necessary clinical documentation to support a diagnosis. A query written just to confirm the diagnosis will not be enough to prevent outside auditor denials. The goal is to obtain the necessary documentation to reflect the provider’s rationale or clinical decision making.

As with any query, the coder will start with clinical indicators. For a clinical validation query, the indicators a coder uses may actually be a lack of positive indicators, such as normal diagnostics, and absence of supporting symptoms or appropriate treatment for the diagnosis. The query options should present an opportunity for the provider to document additional clinical indicators that he/she used in making the diagnosis.

Here is an example of a clinical validation query:

Clinical Indicators:


(ED) T 100.3, P 60, R 12, BP 120/60, oriented x 3, dysuria
(HP) Admitted with UTI, started on IV antibiotics
(Lab) Urine culture E. coli, no blood culture performed, WBC 14.0, procalcitonin 0.6, lactic acid 1.7
(DS) Discharged on day 2 on oral antibiotics, Diagnosis: Sepsis due to UTI

Can you clarify the documented diagnosis of sepsis?

*Sepsis ruled in (Please document any additional clinical indicators supportive of your diagnosis of sepsis below) 

*Sepsis ruled out after study
*Unable to determine


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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