A comprehensive guide to provider query best practices, ICD-10-CM chapter templates, and medical coding training — brought to you by AGES Coding TECH, part of JVAGES Health Care Pvt. Ltd.
Table of Contents
Introduction
Instructions, Example Templates, Clinical Validation
Chapters 1–5
Infectious Diseases, Neoplasm, Blood Disorders, Endocrine, Mental Health
Chapters 6–10
Nervous System, Eye, Ear, Circulatory, Respiratory
Chapters 11–15
Digestive, Skin, Musculoskeletal, Genitourinary, Pregnancy
Chapters 16–21
Perinatal, Congenital, Symptoms, Injury, External Causes, Health Factors
Resources & Contact
AGES Coding TECH, JVAGES Learning App, HR Support
Introduction: The Provider Query Process
The provider query is a common communication tool and educational method used to advocate for proper documentation practices. Querying the provider is a standard procedure in clinical documentation integrity (CDI) and coding, and a core theme in the AHA's Coding Clinic® for ICD-10-CM and ICD-10-PCS.
A compliant query process benefits hospital compliance with billing and coding rules and serves as an educational tool for providers, CDI professionals, and coding professionals. Proper query responses improve accuracy, completeness, reimbursement, and severity of illness (SOI) and risk of mortality (ROM) classifications.
Governing Bodies & Regulatory Framework
AHA
American Hospital Association — publishes Coding Clinic guidance
AHIMA
American Health Information Management Association — issues compliant query practice briefs
NCHS
National Center for Health Statistics — maintains ICD-10-CM classification
CMS
Centers for Medicare and Medicaid Services — oversees ICD-10-CM/PCS Official Guidelines
These four Cooperating Parties are jointly responsible for the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting.
When to Query: Clinical Indicators
Missing Diagnosis
Clinical indicators present but no documented condition
Higher Specificity Needed
Clinical evidence supports a higher degree of specificity or severity
Cause-and-Effect Uncertainty
Unclear relationship between two conditions or organisms
Treatment Without Diagnosis
Only treatment is documented without a corresponding diagnosis
When to Query: Additional Triggers
POA Status
Present on admission indicator status requires clarification
Clinical Validation
Diagnosis requires clinical validation or confirmation
Abnormal Test Results
Clinical significance of abnormal lab or diagnostic findings
Laterality
Laterality cannot be determined from existing documentation
PCS Specificity
Insufficient info to assign root operation, body part, approach, device, or qualifier
Seven Criteria for Documentation Quality
A provider query may also be appropriate when documentation fails to meet any of these seven criteria:
Documentation must also support the intensity of patient evaluation, describe medical decision-making complexity, include all procedures and results, and capture all conditions affecting treatment or length of stay.
The Query Process: Timing & Format
When Queries May Be Generated
Concurrently
While the patient is still an inpatient
Prebill
Prior to claim submission
Retrospectively
Post billing
Format Requirements
- Written, electronic, and email queries must follow HIPAA security regulations
- Verbal and telephonic queries follow the same format as written queries
- All queries must be clear, concise, and non-leading
- Include both supporting and conflicting documentation
- Itemize clinical indicators from the health record
Query Content Requirements
Patient Identification
Name, date of admission or service, discharge date (if applicable), and unit
Clinical Synopsis
A summary of the encounter up to the time the query is written, supporting the query's intent
Clinical Indicators
Itemized findings from nursing notes, labs, radiology, and primary provider documentation
Specific Question
A clear, concise question for the provider with appropriate multiple-choice options
Required Query Response Options
Every multiple-choice query must include "Other explanation of clinical findings" and "Unable to determine" as required options. Optional options include "Findings of no clinical significance" and "No further clarification needed" depending on organizational policy.
Example Template: Generic Query Format
Dear [insert provider name],
[Insert the unspecified documentation] was documented within the [insert location and date]. Clinical Indicators: [Add pertinent clinical indicators from the current health record].
Based on the clinical indicators and your professional judgment, [insert appropriate question]. Please complete by selecting one of the options below.
Option A
Diagnostic option (non-leading)
Option B
Diagnostic option (non-leading)
Other
Other explanation of clinical findings (REQUIRED)
Unable
Unable to determine (REQUIRED)
Miscellaneous: Clinical Validation Example
Case Scenario: Mr. Jones, 84-year-old, admitted with burning urination. ER vitals: HR 115, RR 25, Temp 101.5. Labs: WBC 17.1, Cr 1.1 (unknown baseline), Na 129. UA shows UTI. Given IV fluid bolus and antibiotics. Follow-up labs: Cr 1.0, Na 132. Admitted with Sepsis due to UTI, hyponatremia, and AKI.
Dear Dr. Smith, AKI was documented within the ED note dated xx/xx with a Cr of 1.1 (unknown baseline). Given fluid bolus in ED with follow-up Cr of 1.0. Clinical Indicators: Cr 1.1 on admission requiring fluid bolus, and a UTI. Based on your professional medical judgment, can you confirm this diagnosis?
AKI Ruled Out
AKI Ruled In
Please document supporting evidence
Other Explanation
Unable to Determine
Certain Infectious and Parasitic Diseases
Case Scenario: Mr. Smith, 45-year-old male with history of IV drug abuse and HIV, admitted with productive cough, fever, and chest X-ray showing left lower lobe infiltrate. Vitals: Temp 103.5, HR 125, RR 25, BP 90/60. Labs: WBC 17.1, Lactate 5.0, Cr 3.0, Na 125. History of hyponatremia, AKI, and HIV. Treated with IV normal saline, IV fluids at 150cc/hr, and antibiotics.
Chapter 1: HIV/AIDS Query
Dear Dr. Jones, HIV was documented within the ED documentation dated xx/xx with a positive HIV lab finding. Clinical Indicators: Previous CD4 count <200, previous thrush, history of IV drug abuse, current diagnosis of recurrent pneumonia.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified?
HIV with Associated Diagnosis
Please specify associated condition
Asymptomatic HIV Infection
AIDS
Other / Unable to Determine
Chapter 1: Severe Sepsis with Organ Dysfunction
Dear Dr. Jones, Recurrent pneumonia was documented within the ED note dated xx/xx; HIV also noted. Clinical Indicators: leukocytosis, tachycardia, elevated temp 103.5, lactate 5.0, tachypnea, acute kidney injury, recurrent pneumonia, normal saline, antibiotics.
Based on the clinical indicators and your professional judgment, please clarify/specify with an applicable diagnosis.
Severe Sepsis with Organ Failure
Please specify the organ failure
Sepsis Without Organ Failure
AKI Due to Other
Please specify
Other / Unable to Determine
Neoplasm: Pathology Clarification
Case Scenario: Patient admitted unable to catch his breath acutely. Chest X-ray showed a mass in the middle right lobe and elevated D-dimer. Underwent biopsy; pathology returned non-small cell lung cancer of the right middle lobe. Pain controlled with medication; discharged to follow-up with Oncology. Discharge summary documents "lung mass."
Chapter 2: Pathology Clarification Query
Dear Dr. Smith, Pathology results on xx/xx note the lung mass biopsy shows non-small cell lung cancer. He was noted on discharge summary to have a lung mass. Clinical Indicators: shortness of breath, severe back pain, elevated D-dimer, lung biopsy pathology showing non-small cell lung cancer.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified?
Agree with Pathology
Non-small cell lung cancer of the middle right lobe confirmed
Disagree with Pathology
Other Explanation
Unable to Determine
Diseases of the Blood and Blood-forming Organs
Case Scenario: Ms. Samson, 65-year-old female, admitted for posterior spinal fusion T5–L4 for thoracic and lumbar spinal stenosis. Pre-op Hgb 13.1, HCT 40.0. Intra-op blood loss of 900cc; given 2L IVF and 1-unit PRBCs. Two days post-op Hgb dropped to 8.0; administered 2 units PRBCs with Hgb recovery to 12.0. Discharged with spinal stenosis and low hemoglobin.
Chapter 3: Anemia Type Query
Dear Dr. Jones, Low hemoglobin was documented within the health record H&P on xx/xx with post spinal fusion surgery. Based on the clinical indicators and your professional judgment, can an associated diagnosis be documented?
Acute Blood Loss Anemia
Anemia of Chronic Disease
Please specify the chronic disease
Other Type of Anemia
Findings of No Clinical Significance
Other / Unable to Determine
Endocrine, Nutritional, and Metabolic Diseases
Case Scenario: Ms. Smith, 22-year-old female, admitted with newly diagnosed colorectal cancer. Extremely weak, vomiting several times daily for three days, BMI 15, 45-pound weight loss in six months. Labs show hyponatremia and hyperkalemia. NG tube placed; parenteral nutrition and IV fluids started. RD noted severe protein malnutrition with Aspen criteria: severe muscle and fat loss with extreme weight loss. Provider notes malnutrition and cachexia.
Chapter 4: Malnutrition Severity Query
Dear Dr. Jones, Malnutrition was noted within the health record progress note on xx/xx. Clinical Indicators: BMI 15, weakness, RD noted severe malnutrition with Aspen criteria, colorectal cancer, 45-pound weight loss, parenteral nutrition, normal saline, cachexia.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified?
Severe Protein Calorie Malnutrition
Findings of No Clinical Significance
Other Explanation
Unable to Determine
Mental, Behavioral, and Neurodevelopmental Disorders
Case Scenario: Mr. Smith, 53-year-old male, admitted with aggressive behavior after drinking an entire bottle of vodka. Blood alcohol level of 300. Required restraints in ED. Placed on CIWA scale, psych consult ordered, banana bag started. Wife reports daily alcohol use, never sought treatment, and behavior can be aggressive but he had never been incoherent before.
Chapter 5: Alcohol Specificity Query
Dear Dr. Jones, Aggressive behavior was documented within the ED note on xx/xx after consuming alcohol. Clinical Indicators: behavioral changes, intoxication, blood alcohol level of 300, alcohol use, CIWA protocol, banana bag, psych consult ordered.
Based on the clinical indicators and your professional judgment, can an associated diagnosis be documented?
Alcohol Abuse
Specify if associated mood disorder, intoxication, or withdrawal
Alcohol Dependence
Specify if associated mood disorder, intoxication, or withdrawal
Alcohol Use
Specify if associated mood disorder, intoxication, or withdrawal
Other / Unable to Determine
Diseases of the Nervous System
Case Scenario: Mr. Jones, 25-year-old male, admitted from home after consuming an unknown amount of Ativan with altered mental status and drowsiness. Incoherent and not responding appropriately to questions. Past history of drug abuse and two prior overdose admissions. Poison control contacted, IVFs initiated, soft restraints applied.
Chapter 6: Altered Mental Status Query
Dear Dr. Smith, Altered mental status was documented within the H&P on xx/xx due to Ativan consumption. Clinical Indicators: altered mental status, drowsiness, requiring soft restraints, drug abuse, IV fluids given.
Based on the clinical indicators and your professional judgment, can an associated diagnosis be documented?
Toxic Encephalopathy
Please specify substance
Encephalopathy, Etiology Unknown
Delirium
Please specify acuity and underlying cause
Other / Unable to Determine
Diseases of the Eye and Adnexa
Case Scenario: Mr. Jones, 65-year-old male, admitted with diabetic retinopathy and extreme eye pain. Also experiencing headache and blurred vision. Pain intensity prompted the ED visit. He is noted to have glaucoma and requires surgical drainage with emergency treatment.
Chapter 7: Glaucoma Specificity Query
Dear Dr. Smith, Glaucoma was documented within the ED note on xx/xx with known diabetic retinopathy and new symptoms requiring ED visit. Clinical Indicators: blurred vision, eye pain, headache, diabetes, surgery is indicated.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified?
Open-Angle Glaucoma
Please specify stage: mild, moderate, or severe
Angle-Closure Glaucoma
Please specify stage: mild, moderate, or severe
Other Explanation
Unable to Determine
Diseases of the Ear and Mastoid Process
Case Scenario: Non-verbal child with known Trisomy 21 brought in for possible ear infection. Pulling at ear and grimacing in pain. No known fever; vitals stable. Examination reveals otitis media with fluid in the ear. Started on antihistamine; ENT consulted for possible outpatient tube placement.
Chapter 8: Otitis Media Specificity Query
Dear Dr. Smith, Otitis Media was documented within the ED note dated xx/xx with fluid found in the ear. Clinical Indicators: ear pain, fluid in the ear, consult for possible ear tubes outpatient, antihistamine prescribed.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified?
Serous Otitis Media
Please specify if acute or chronic
Suppurative Otitis Media
Please specify if acute or chronic
Mucoid Otitis Media
Please specify if acute or chronic
Other / Unable to Determine
Diseases of the Circulatory System
Case Scenario: Ms. Smith, 65-year-old female, admitted for shortness of breath with accessory muscle use. History of hypertension and obesity. Chest X-ray shows bilateral pleural effusions. Echo from two weeks prior shows EF of 45%. Given IV Lasix in ED; breathing improves on floor. Cardiology consult ordered. Admitted with likely CHF exacerbation, newly found.
Chapter 9: Heart Failure Specificity Query
Dear Dr. Jones, CHF was documented within the health record note dated xx/xx with likely exacerbation newly found. Clinical Indicators: shortness of breath, EF 45%, accessory muscle use, hypertension, obesity, treated with Lasix. Diagnostic Findings: Echo with EF 45%, chest X-ray with bilateral pleural effusions.
Acute Systolic CHF
Acute Diastolic CHF
Acute on Chronic Systolic CHF
Acute on Chronic Diastolic CHF
Other / Unable to Determine
Diseases of the Respiratory System
Case Scenario: Ms. Jones, 65-year-old female, admitted with shortness of breath. History of COPD with home O2 at 2L all day. O2 needs escalated to 7L with head bobbing and accessory muscle use. Consent obtained for possible intubation; started on BIPAP. Administered Solu-Medrol and Duonebs; admitted to ICU for COPD exacerbation with respiratory distress.
Chapter 10: Respiratory Failure Indicators Query
Dear Dr. Smith, Respiratory distress was documented within the health record note dated xx/xx due to COPD exacerbation. Clinical Indicators: shortness of breath, labored breathing, accessory muscle use with head bobbing, COPD, home O2 with escalation to BIPAP, Solu-Medrol, Duonebs, admitted to ICU.
Based on the clinical indicators and your professional judgment, can an associated diagnosis be documented?
Acute Respiratory Failure
Please specify if associated with hypoxia or hypercapnia
Acute on Chronic Respiratory Failure
Please specify if associated with hypoxia or hypercapnia
Other Explanation
Unable to Determine
Diseases of the Digestive System
Case Scenario: Ms. Jones, 85-year-old female, admitted with melena. Blood noted when wiping, progressively increasing. History of GI bleeds with diverticulitis and ulcerative colitis. Labs: Hgb 9.0, tachycardia 125. Started on Protonix, IVF, GI consult ordered. Physical exam shows internal and external hemorrhoids. Scope after bleeding stabilized shows diverticulosis; no active bleeding source found. Discharged with GI bleed and acute blood loss anemia.
Chapter 11: Gastrointestinal Bleeding Query
Dear Dr. Smith, GI bleed was documented within the health record note dated xx/xx with extensive GI history. Clinical Indicators: blood in stool, tachycardia, history of diverticulitis, history of ulcerative colitis, GI consult, evidence of internal and external hemorrhoids.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified? Please specify the etiology/source of the GI bleed.
Diverticulosis
With or without diverticulitis
Hemorrhoids
Other Condition
Please specify
Unable to Determine
Diseases of the Skin and Subcutaneous Tissue
Case Scenario: Ms. Smith brought from home (bed bound), unable to care for herself. Severely cachectic with severe malnutrition; requires skilled nursing facility placement and nutrition consult. Day 3 of admission: nursing notes a stage 2 pressure ulcer on sacrum treated with Mepilex and turning every two hours. Provider notes patient will be placed in skilled nursing facility.
Chapter 12: Skin Ulcer Specificity Query
Dear Dr. Jones, Stage 2 pressure ulcer was documented within the nursing skin flow-sheet on xx/xx located on the sacrum. Based on the clinical indicators and your professional judgment, can an associated diagnosis be documented?
Pressure Ulcer/Injury
Please specify stage, location, and if present on admission
Non-Pressure Ulcer
Please specify
Other Explanation
Unable to Determine
Diseases of the Musculoskeletal System and Connective Tissue
Case Scenario: Ms. Smith, 65-year-old female, admitted following a left femur fracture at the head of the femur. Tripped over a cord at home and felt immediate pain when trying to stand. History of osteoporosis; takes daily calcium supplements. Ortho admitting for probable surgical intervention.
Chapter 13: Pathological vs. Traumatic Fracture Query
Dear Dr. Jones, Femur fracture was documented within the health record note on xx/xx following a fall. Clinical Indicators: fall at home from standing/tripped over a cord, history of osteoporosis on supplements.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified?
Pathological Fracture of the Femur
Please specify cause if known
Traumatic Fracture of the Femur
No underlying pathological cause
Other Explanation
Unable to Determine
Diseases of the Genitourinary System
Case Scenario: Mr. Johnson, 65-year-old male, admitted with swelling and decreased urine output (no urine since yesterday AM). Cr 5.0 with baseline of 2.0. Nephrology consulted for possible emergent dialysis. Temp 103, HR 125; blood cultures drawn. Foley placed with dark urine return; UA confirms UTI. Blood cultures negative. Admitted with sepsis due to UTI with AKI on CKD. Nephrologist notes historical GFR of 45.
Chapter 14: CKD Staging Query
Dear Dr. Jones, AKI on CKD was documented within the health record note dated xx/xx; admitted with sepsis due to UTI. Clinical Indicators: decreased urine output, abnormal GFR of 45, sepsis due to UTI, dialysis performed.
Based on the clinical indicators and your professional judgment, can the stage of CKD be further specified?
CKD Stage 2
CKD Stage 3
Other Stage of CKD
Please specify
Other / Unable to Determine
Pregnancy, Childbirth, and the Puerperium
Case Scenario: Mrs. Johnson, 39-year-old female, high-risk pregnancy due to advanced maternal age, morbid obesity, hypertension, and gestational diabetes. Admitted for pre-term contractions at 30 weeks with severe headache. BP 150/90; home medication Labetalol 200mg 2x/day (missed morning dose). IVF started; Labetalol given with BP improvement to 125/80. Steroid shot administered; placed on bedrest.
Chapter 15: Hypertension in Pregnancy Query
Dear Dr. Jones, Hypertension was documented within the health record note on xx/xx with possible pre-term labor. Clinical Indicators: severe headaches, advanced maternal age, obesity, gestational diabetes, bedrest, antihypertensives.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified?
Gestational Hypertension
Pre-existing Hypertension
Please specify underlying cause: heart disease, renal disease, etc.
Other Explanation
Unable to Determine
Certain Conditions Originating in the Perinatal Period
Case Scenario: Baby Smith born via c-section at 29 weeks gestation, weighing 1250 grams. Extreme distress at birth with apnea and hypoxia, no respiratory effort; resuscitation required and intubated. Brought to NICU on ventilation; chest X-ray performed, surfactant administered, baby stabilized. NG placed; warmer used for low temps. Antibiotics started due to temp variation and unknown GBS status. Monitored for premature complications: anemia, hyperbilirubinemia, sepsis, ROP.
Chapter 16: Neonatal Respiratory Distress Query
Dear Dr. Johnson, Respiratory distress was documented within the health record note on xx/xx requiring intubation and surfactant. Clinical Indicators: hypoxia, apnea, no respiratory effort at birth, ventilator, surfactant.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified?
Respiratory Distress Syndrome (Cardiorespiratory) Type 1
Respiratory Failure of Newborn
Other Explanation
Unable to Determine
Congenital Malformations, Deformations, and Chromosomal Abnormalities
Case Scenario: Jack Smith, six-month-old boy, with persistent reflux and occasional projectile vomiting. Brought in appearing dehydrated, lethargic, and not eating. Scope of upper GI shows definite stricture in the esophagus. Admitted for temporary feeding tube placement. Primary doctor documents GERD, dehydration, and need for feeding tube.
Chapter 17: Congenital Malformation of the Esophagus Query
Dear Dr. Jackson, GERD was documented within the health record note dated xx/xx with feeding tube placement. Based on the clinical indicators and your professional judgment, can an associated diagnosis be documented?
Congenital Stenosis and Stricture of Esophagus
Other Explanation of Clinical Findings
Unable to Determine
No Further Clarification Needed
Symptoms, Signs, and Abnormal Clinical and Laboratory Findings
Case Scenario: Mr. Paul, 35-year-old male, admitted with nausea and vomiting for two days. Na 129, K 4.0, Cr 1.2, WBC 11.0, Hgb 15.0. Headache and dehydration prompted ED visit. Vitals: Temp 99.9, HR 110, RR 18. Noted with likely viral gastroenteritis; given IVF for dehydration.
Chapter 18: Supporting Diagnosis Query
Dear Dr. Smith, Dehydration was documented within the ED note dated xx/xx; patient given IVF with Na level of 129. Clinical Indicators: nausea and vomiting, headache, normal saline given, dehydration.
Based on the clinical indicators and your professional judgment, can an associated diagnosis be documented?
Hyponatremia
Finding of No Clinical Significance
Other Explanation
Unable to Determine
Injury, Poisoning, and Certain Other Consequences of External Causes
Case Scenario: Ms. Smith, 65-year-old female, admitted with altered mental status and femur fracture after falling at home. Husband reports she took her normal Xanax dosage but became lethargic, fell down stairs, and broke her leg. Pill bottle shows fewer pills than expected; she may have taken more than usual or taken a different similar-looking medication. Admitted with femur fracture and likely toxic encephalopathy from Xanax.
Chapter 19: Adverse Effect vs. Poisoning Query
Dear Dr. Johnson, Likely toxic encephalopathy from Xanax was documented within the health record note dated xx/xx. Clinical Indicators: altered mental status on admission, drowsy and lethargic, fall at home with subsequent broken femur, and evidence of missing pills.
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified?
Adverse Effect
Medication taken appropriately with proper dosage — please state the medication
Poisoning
Wrong dosage or wrong medication — please state medication and intention (intentional/not intentional)
Other Explanation
Unable to Determine
External Causes of Morbidity
Case Scenario: Mr. Jones, 15-year-old male, admitted with skull fracture, femur fracture, kidney laceration, and punctured lung after being hit by an automobile. "Do not walk" signal was active; bystanders report he appeared to be texting. Currently intubated; psych consulted for possible intentional self-harm. Three days in: psych reports no known suicidal ideations per family; recent difficult break-up noted. Phone records confirm texting at time of accident.
Chapter 20: Self-Harm vs. Accident Query
Dear Dr. Johnson, Walking into oncoming traffic was documented within the health record note dated xx/xx with subsequent life-threatening injuries. Clinical Indicators: skull fracture, femur fracture, kidney laceration, punctured lung, ventilated and induced coma.
Based on the clinical indicators and your professional judgment, can this be further specified?
Intentional Self-Harm
Accidental Harm
Other Explanation
Unable to Determine
Factors Influencing Health Status and Contact with Health Services
Case Scenario: Ms. Jackson admitted for pre-term contractions with no prenatal care; unsure of gestational age. Thinks last menstrual cycle was about eight months ago. Ultrasound shows breech presentation; baby weighs approximately six pounds. Water has broken; c-section performed. Baby appears fully formed without distress but with thick Vernix layer; taken to NICU for observation.
Chapter 21: Weeks of Gestation Query
Dear Dr. Jones, Possible pre-term labor was documented within the health record note dated xx/xx but term is unknown due to lack of prenatal care. Clinical Indicators: water broke, baby is breech, c-section, infant fully formed without distress, thick layer of Vernix.
Based on the clinical indicators and your professional judgment, can the term of pregnancy be further specified?
30–39 Weeks
Please specify the last completed week
40–42 Weeks
Please specify the last completed week
Other Explanation
Unable to Determine
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AGES Coding TECH – Clinical Documentation & Query Toolkit