Simplifying query systems in healthcare can lead to discussions about the appropriateness of offering only a single possible diagnosis. A common concern revolves around whether limiting options to a Singular Diagnosis constitutes a “leading” query. This question is crucial for maintaining compliant and effective Clinical Documentation Improvement (CDI) practices.
According to the ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice,” a leading query is defined as one that lacks support from clinical elements within the health record, or one that directs a provider towards a specific diagnosis or procedure. The emphasis here is on clinical justification. The guidelines further specify that multiple-choice query formats should include clinically significant and reasonable options, acknowledging situations where only one reasonable option may exist.
These recommendations emphasize offering “any/all reasonable options,” alongside “other,” and “unable to determine” choices. The critical phrase is “any reasonable options.” In scenarios where patient-specific clinical indicators point to only one clear and reasonable diagnosis, it becomes not only acceptable but also most accurate to present just that singular diagnosis. This should always be accompanied by the options “other” and “unable to determine” to maintain query integrity.
Adding diagnoses that are not clinically supported by the patient’s presentation solely to broaden the choices in a query is counterproductive and can be misleading. The goal of a compliant query is to accurately reflect the clinical picture, not to provide an artificially wide range of options.
Historically, there was a practice of including multiple choices in queries, some affecting reimbursement and others not, with the intention of making queries appear more compliant and less leading. This approach, however, often forced the inclusion of diagnoses that were not clinically valid for the patient’s condition, just to fill out the list of choices.
The updated guidance on query practices clarifies that offering choices not substantiated by the patient’s clinical indicators actually constitutes a leading query. Therefore, CDI specialists should focus on presenting only those choices that genuinely align with the patient’s clinical presentation. In many instances, a singular diagnosis is indeed the most appropriate and compliant option.
To ensure consistent practices within healthcare organizations, reviewing the query practice brief and highlighting sections addressing leading and non-leading queries, as well as the development of multiple-choice queries, is highly beneficial. This exercise can foster valuable dialogue between coding and CDI staff, potentially leading to improvements in internal processes and a clearer understanding of compliant query practices, particularly concerning the use of a singular diagnosis when clinically indicated.
Editor’s Note: This expert insight was provided by CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer. For further information on CDI Boot Camps offered by HCPro, please visit www.hcprobootcamps.com/courses/10040/overview. This article was originally published on the ACDIS Blog.
