2022 Update — The definitive industry reference for clinical documentation integrity query compliance, published jointly by AHIMA and ACDIS.
Published By
This practice brief represents the joint efforts of the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Integrity Specialists (ACDIS), two of the most respected organizations in health information management.
It supersedes all previous versions and establishes updated, authoritative best practices for compliant query processes across all healthcare settings.
Purpose of This Practice Brief
"This practice brief is intended to provide best practice standards for the clinical documentation integrity query process that is driven by the underlying goal of validating the clinical documentation within the health record accurately represent the clinical status of the patient."
The AHIMA-ACDIS Practice Brief serves as an essential resource for coding and clinical documentation integrity (CDI) professionals across all healthcare settings — including inpatient and outpatient environments. It is designed to guide anyone who participates in query or documentation clarification processes.
This guidance applies broadly: quality management, compliance, revenue cycle, patient financial services, physician groups, facility leaders, care management, and any professional whose work impacts health record documentation for reimbursement, medical necessity, quality measures, or clinical coding.
Who Should Use This Brief
CDI & Coding Professionals
Primary users responsible for query generation, documentation clarification, and code assignment accuracy.
Payers & Auditors
External reviewers including OIG, government contractors, and payer agencies evaluating provider queries and documentation.
Compliance & Legal
A reference tool for compliance officers and legal counsel in evaluating query practices and organizational policy.
Facility Leaders
Administrators and physician groups shaping organizational policy to align with recognized industry standards.
Specific Use Examples of the Practice Brief
The guidelines are designed to be practical and actionable. Below are key applications across your organization — from onboarding new staff to defending compliance in external audits.
Orienting & Educating Staff
Use the brief to orient new employees and update current staff on compliant query standards and expectations.
Policy Development
Review and update query policies and procedures to ensure alignment with industry-recognized compliant practices.
Audit Standards
Assist with development of query audit frameworks that support both qualitative and quantitative assessment.
Standardization Across the Industry
Provide a consistent reference tool for compliance, legal matters, and third-party stakeholder education.
Billing Impact Education
Educate team members on how compliant query practices directly affect organizational and professional billing outcomes.
General Query Standards
The following foundational standards establish the language, scope, and roles governing all queries. Understanding these definitions is the first step toward building a truly compliant query practice.
Defining the Query
A query may be developed by a healthcare professional or through a computer autogenerated query process. The term "query" encompasses a broad range of communication tools — regardless of what they are called within an organization.
Possible Terms That May Meet the Definition
Clarification, clinical clarification, documentation clarification, prompt, nudge, alert, and similar terms. If it meets the definition of a query, it is a query — regardless of the label used.
Code Assignment
Throughout this brief, "code assignment" refers to any diagnosis, procedure, or service code — covering both ICD-10-CM/PCS and CPT coding systems.
Encounter
The term "encounter" is used throughout to describe all patient encounter types for both inpatient and outpatient settings — including admissions, hospital stays, office visits, and outpatient stays.
Ambiguous Documentation & Query Professionals
Ambiguous Documentation Defined
Documentation that fails to reflect the provider's intent, impacts the clinical scenario (e.g., diagnoses, complications, quality of care), the accuracy of code assignment, and/or the ability to assign a code at all.
Identifying ambiguous documentation is a core trigger for initiating a compliant query.
Who Are Query Professionals (QP)?
Query Professionals are those who use the query process to resolve documentation issues and/or have oversight and involvement in the query process. This includes:
- Coding professionals
- CDI professionals
- Physician and provider advisors
- All professionals who initiate communication meeting the query definition
Any QP can initiate a query by following these compliant guidelines.
General Query Guidelines
These guidelines establish the operational requirements for developing, sending, and managing queries throughout the healthcare documentation process. Every compliant query must meet the following core standards.
Meeting all four requirements ensures the query supports documentation integrity without introducing bias or leading the provider toward a predetermined response.
Query Requirement: Answer Options
Multiple-choice queries are a common and effective format. Constructing answer options correctly is critical to maintaining compliance and provider trust.
Clinically Supported Options
Include only those answer options supported by clinical indicators within the health record. Exclude clinically irrelevant options (e.g., do not offer hypernatremia when sodium is 122).
"Other" Is Always Required
Multiple-choice queries must always include "other" (or similar terminology) to allow the provider to customize their response. There is no mandatory maximum or minimum number of answer options.
Optional Answer Options
Options such as "unknown," "not clinically significant," "integral to," "unable to rule out," or "inherent to" may be used but are not required in every query.
No Reimbursement References
Never include reference to reimbursement impact, quality measures, or other reportable data within a query or its answer options.
Understanding "Unable to Determine"
Definition
The provider is clinically unable to determine if a diagnosis or further clarity can be provided in the documentation. This is distinct from an uncertain diagnosis (e.g., possible, probable, unlikely).
When It Is Required
"Unable to Determine" is a required option in all POA (Present on Admission) and Yes/No queries. It is not automatically required for all multiple-choice queries.
Escalation Consideration
When "Unable to Determine" is selected, the response may be reviewed on a case-by-case basis to determine whether further escalation of the query is warranted.
When to Query
Queries may be necessary across a broad range of clinical documentation scenarios. Understanding the appropriate triggers helps ensure compliant, purposeful query initiation — and prevents both over-querying and missed opportunities for documentation accuracy.
Appropriate Triggers for Querying
Clinically Evident Diagnoses
To support documentation of medical diagnoses that are clinically evident and meet UHDDS requirements but have no corresponding stated diagnosis in the health record.
Conflicting Documentation
To resolve conflicting diagnostic or procedural documentation between providers, or when a documented diagnosis appears to lack clinical support (clinical validation).
Encounter Clarification
To clarify the reason for an inpatient or outpatient encounter, or to confirm a diagnosis documented by an independent licensed practitioner not meeting the provider definition.
Cause-and-Effect Relationships
To establish a cause-and-effect relationship between medical conditions, or to clarify the presence or absence of a complication, including post-operative complications.
POA Status & Procedure Extent
To support appropriate Present on Admission (POA) indicator assignment, determine if a diagnosis is ruled in or out, and clarify the objective and/or extent of a procedure.
Additional Query Triggers
Active vs. History Conditions
A query may be needed to establish the relevance of a condition documented as a history or as active. This distinction directly impacts code assignment and clinical reporting accuracy.
Ancillary Note Diagnoses
When a diagnosis appears in an ancillary note that has been signed by a provider but is not addressed within the provider's own documentation, a query may be necessary. For example, if a nutrition note states "severe malnutrition" and is provider-signed, but the provider does not independently address that diagnosis.
Procedure Clarification
To clarify the objective and/or extent of a procedure performed, ensuring the coded procedure accurately reflects what was clinically carried out and documented by the performing provider.
Complication Presence or Absence
To clarify whether a complication is present or absent — particularly important for hospital-acquired conditions (HACs), patient safety indicators (PSIs), and quality reporting accuracy.
When NOT to Query
No Business Need or Clinical Impact
Queries are not necessary for every discrepancy. When there is no business need or the issue does not add clarity to the clinical picture, a query should not be sent.
Insufficient Record to Clarify
Do not query if the provider cannot offer clarification based on the present health record documentation. A query cannot create clinical information that does not exist.
Valid Code Already Assignable
When sufficient documentation exists to assign a valid code and no indicators suggest higher specificity, querying is not required. Code accuracy is not the same as code specificity — ICD-10-CM requires codes to the highest characters supported by documentation, not the most specific code available.
Clinical Data Does Not Support Options
Queries should only be generated when the clinical data (present and relevant historical data) fully supports the answer choices offered to the provider.
Sending Multiple Queries
When Multiple Queries Are Appropriate
Verbal queries may be used when multiple queries are required for the same set of clinical indicators in complex, ambiguous cases. For example, when both a diagnosis and additional specificity must be established simultaneously — such as clarifying the presence and the specific type of heart failure.
A second query may be needed as additional information becomes available or as the clinical picture evolves after a prior query has been answered.
Organizational Policy Guidance
Organizations should develop written policies to address:
- The number of queries that may be simultaneously placed on a single encounter
- Guidance on prioritizing query focus when multiple documentation issues exist
- How many topics and questions may be issued on a single query form
- How to manage complex cases where documentation evolves over the course of care
Compliant Query Guidelines
The objective of a query is to ensure that reported diagnoses and procedures derived from health record documentation accurately reflect the patient's episode of care. Compliant query practice is built on a set of non-negotiable tenets that protect both providers and organizations.
The Five Tenets of Compliant Query Practice
Clinically Supported Options
Provide multiple-choice answer options supported by clinical indicators from the health record, which must also be included within the query itself.
Evidence-Based New Diagnoses
Diagnosis options not already documented must be supported by clinical indicators sourced from the medical record, with those indicators explicitly included in the query.
Non-Leading Query Titles
Titles of queries visible to providers must be non-leading and must not include reimbursement impact, quality indicators, specific undocumented diagnoses, or the desired response.
Specific Clinical Indicators
Queries must be accompanied by clinical indicators specific to the patient and episode of care, supporting a more complete or accurate diagnosis or procedure.
Rare Use of Uncertain Diagnoses
In the inpatient setting, uncertain diagnosis language (e.g., "likely," "probable") should rarely be used unless the provider has already documented using terms of uncertainty.
Problem Lists & Query Practice
A problem list includes active diagnoses relevant to the current episode of care. Organizations must develop policies and procedures related to compliant query practices and the maintenance of problem lists — including who can update a problem list following a query response.
Problem list maintenance should reflect clinical reality, not financial optimization. Any update following a query response must be grounded in the clinical documentation and the provider's authenticated response, not in coding or reimbursement outcomes.
Query Template Guidelines
Query templates promote efficiency, consistency, and compliance across an organization. However, templates must be carefully designed, regularly reviewed, and consistently applied to ensure they remain aligned with compliant query standards.
Standards of Use for Query Templates
Policy Development
Establish policies and procedures for creating, reviewing, and updating query templates — including input from providers and relevant clinical disciplines.
Regular Review Schedule
Review and update templates on a regular schedule — at minimum annually, and whenever process changes occur — to ensure continued compliance.
Usage Instructions
Provide clear instructions on proper template use to all query professionals. Templates must align with all other standards and criteria identified in this practice brief.
Template Format Requirements
Templates should include patient identification (if not auto-populated in the EHR) and a topic title that is non-descript and does not identify an undocumented diagnosis.
Template Answer Options & Clinical Indicators
Answer Option Requirements
Template answer options should:
- Offer only clinically credible multiple-choice options
- Allow removal of embedded options that are not clinically credible or relevant
- Be worded to allow for accurate code assignment
- Carry no mandatory or minimum number of diagnosis/procedure options
Clinical Indicator Elements
Templates must allow for inclusion of relevant clinical indicators and evidence to support the query. All clinical indicators should include a citation identifying the location found within the health record — such as note type, date, and author — enabling the provider to independently verify the referenced information.
Provider Education
Provider education is a vital and often underutilized component of a successful query program. Queries alone are insufficient to drive lasting documentation improvement — providers must understand the process, their role in it, and the clinical and operational stakes involved.
Building a Sustainable Provider Education Program
Regular, Scheduled Education
Offer education and examples to providers on a regular schedule so they become comfortable reading and responding to queries. Consistent exposure builds understanding of their role in the documentation process and improves response quality and timeliness.
Use Real-World Case Studies
Provider education may utilize case studies with actual queries to make learning concrete and relevant. Patient identifiers must be removed from all materials to protect privacy and comply with HIPAA requirements.
Beyond Queries Alone
Queries alone may not provide enough information to guide providers toward delivering clinical documentation integrity. Education should contextualize the "why" behind queries — including the impact on reimbursement, quality metrics, and patient care continuity — without using reimbursement as a lever within the query itself.
Role of Prior Encounters in Queries
Code assignment is determined by documentation from the current encounter. However, querying using evidence from prior encounters may be appropriate and compliant when that information is clinically pertinent to the present episode of care.
The key distinction is whether a trigger in the current encounter justifies the review. Without a present-encounter trigger, reviewing prior records solely to generate queries constitutes non-compliant "mining."
Compliant Uses of Prior Encounter Information
Diagnostic Criteria & Specificity
Confirming the type of heart failure, specific arrhythmia, or stage of chronic kidney disease (CKD) when CKD is documented in the current encounter.
Baseline Determination
Determining the patient's prior baseline allows comparison to the current presentation — essential for assessing the clinical significance of acute changes.
Cause-and-Effect Relationships
Clarifying post-operative complications, exposure to a causative organism, or etiology when documentation suggests signs or symptoms related to a prior encounter.
POA Status & History Clarification
Verifying Present on Admission (POA) indicator status and clarifying whether a prior history of a disease — such as a neoplasm — is still active or resolved.
The "Mining" Prohibition
Mining is defined as reviewing a previous health record encounter without any related trigger found in the current encounter — essentially scanning prior records opportunistically rather than in response to a specific, present-encounter need.
A query cannot be based solely on information from a prior encounter. There must always be relevant information within the current encounter to substantiate the query. Organizations should develop policies defining when and for what reasons prior encounters may be reviewed, including guidelines on how far back records may be consulted.
Additionally, the condition or diagnosis being queried must — if documented — satisfy the criteria for "other diagnoses" as defined by ICD-10-CM Official Guidelines, Section III: it must require clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and/or monitoring.
Clinical Indicators
"Clinical indicator(s)" is a broad term encompassing documentation that supports a diagnosis as reportable and/or establishes the presence of a condition. There is no required number of clinical indicators that must accompany a query — what is "relevant" varies by diagnosis, patient, and clinical scenario.
What Clinical Indicators Should Accomplish
Clear & Concise
Clinical indicators must be presented clearly and concisely. The query professional should not add subjective interpretation — for example, if heart rate is 120, the indicator should state "heart rate 120," not "tachycardia."
Directly Support Clarification
Indicators must directly support the condition requiring clarification, painting a clear clinical picture that allows the provider to determine the most appropriate medical condition or procedure.
Specific to the Patient
Indicators must be specific or directly related to the patient and encounter in question. They may be sourced from prior encounters when clinically pertinent to the present encounter.
Support Accurate Code Assignment
Indicators should support documentation that will translate to the most accurate code — not the most specific or highest-weighted code available, but the code most accurately representing the clinical reality.
Sources of Clinical Indicators
Clinical indicators may be sourced from the entirety of the patient's health record. The following sources are commonly used — though this list is not exhaustive:
Selecting the most relevant clinical indicators from across these sources — and clearly citing their location in the health record — is a hallmark of a well-constructed, compliant query.
Who to Query
Queries must be directed to the right provider — one who is delivering direct care to the patient during the specific encounter. Directing queries appropriately protects both documentation accuracy and provider relationships.
Core Rules for Provider Targeting
Direct Care Providers Only
Queries must be sent to and responded to by providers delivering direct care during the specific encounter. It is inappropriate to query a physician advisor who is not providing direct care — for example, sending a query to a physician advisor for a response is non-compliant.
Subject-Matter Matching
When multiple specialists are involved, query the provider most appropriate to the query subject. Do not send a skin ulcer query to the nephrologist, or a surgical debridement query to the hospitalist. Match the query to the provider's area of expertise.
Conflicting Documentation
When conflicting documentation exists across multiple providers, the attending provider should be queried to resolve discrepancies. Refer to ICD-10-CM Official Guidelines I.B.1. for updated 2022 guidance on clinician documentation.
Non-Provider Clinicians
There are occurrences for which it is appropriate to query clinicians not classified as providers for information other than a diagnosis — such as nurses for infusion details, respiratory therapists for mechanical ventilation, or social workers for SDOH clarification.
Non-Provider Clinicians: Appropriate Query Scenarios
Organizations must define in their policies and procedures whether they will query clinicians who are not classified as providers. The following are examples where such queries may be appropriate (not all-inclusive):
Infusion Administration Details
Nurse administering infusions — for clarification of the type, route, and duration of infusion therapy documented in nursing notes.
Wound Care Specifics
Clinicians providing wound care — for clarification of wound characteristics, treatment applied, and clinical findings that support procedure code assignment.
Mechanical Ventilation
Respiratory therapists — for clarification of mechanical ventilation hours, weaning processes, and ventilator management details.
BMI & Nutritional Data
Dietitian — to provide body mass index (BMI) or nutritional assessment data supporting diagnosis documentation.
Social Determinants of Health
Social workers, community health workers, case managers, or nurses — for SDOH clarification relevant to diagnosis coding and care planning documentation.
How to Query
Regardless of format, method, or technology used, all queries must adhere to compliant, non-leading standards — permitting the provider to respond unbiasedly with a specific diagnosis or procedure. The structure, content, and delivery of a query are equally important to its compliance.
Core Principles: How Queries Must Be Written
Non-Leading Language Is Non-Negotiable
A query must not direct (lead) the provider to document a specific response. This includes the use of highlighting, bolding, underlining, italics, or framing a Yes/No query to obtain a new, undocumented diagnosis.
It is non-compliant to continue sending the same query to the same or multiple providers until a desired response is received.
Complete Citation of Clinical Indicators
All relevant diagnoses, lab findings, diagnostic studies, procedures, and other data illuminating the need for a query should be noted and cited by location within the medical record. The provider must be able to independently verify every clinical indicator referenced.
If a compliant query has been properly answered and authenticated by a responsible provider and is part of the permanent health record, it is sufficient for code assignment — the response need not be repeated elsewhere.
Verbal Queries
"There are occurrences for which it is appropriate to query clinicians who are not classified as a provider for additional information (other than a diagnosis)."
Verbal queries must follow the same non-leading, clinically grounded standards as written queries. All conversations seeking documentation clarification must include appropriate clinical indicators and all plausible options.
Timely Documentation Required
The exact date, time, and signature of the query professional; the reason for the query; clinical indicators presented; and options offered must be recorded and tracked in the same manner as written queries.
Must Be Discoverable
Verbal queries should be recorded and tracked so they are discoverable by other departments and external agencies, including auditors and compliance reviewers.
Permanent Health Record Response Required
A response to a verbal query must be documented in the permanent health record in order to be coded. The provider's verbal response alone is insufficient for code assignment purposes.
Written Query Formats
Written queries can take three forms, each suited to different clinical documentation circumstances. Selecting the correct format is key to compliance and provider responsiveness.
Open-Ended
Allows the provider to add free-text responses based on clinical judgment. Responses may or may not align with documentation needed to support code assignment — useful when the clinical picture is complex or multifaceted.
Multiple Choice
Should include clinically significant and reasonable options supported by clinical indicators, plus an "other, please specify" option. There is no mandatory minimum number of choices. Providing a new diagnosis option — when substantiated by referenced clinical indicators — is not introducing new information.
Yes / No
Should only be used to clarify documented diagnoses needing further specification. May NOT be used when only clinical indicators are present and the condition has not been documented. Must include "Unable to Determine" as an option. Best used for POA status, substantiating existing diagnoses, and resolving conflicting documentation.
Query Retention & Record Status
All queries — whether written, verbal, or computer-generated — must be retained according to applicable state regulations and organizational policies. Compliant practice requires that all queries either be a permanent part of the health record or be retrievable in the business record.
Post-Discharge Responses
A query response should be documented in the health record even if the patient has been discharged — in the form of an amendment or the query form itself. If the record is complete, an addendum should be created and authenticated per organizational policy.
Retention Policy Requirements
The query retention policy must specify whether completed queries will be a permanent part of the health record or a business record. Health record status subjects the query to state-specific health record retention guidelines.
Audit & Compliance Discoverability
Queries may be disclosed and are retained for auditing, monitoring, and compliance purposes. All query types — written, verbal, and computer-generated — must be discoverable and retained accordingly.
Organizational Policies & Procedures
Organizations must develop and maintain comprehensive query-related policies and procedures. These policies form the foundation of a defensible, compliant query program and provide the framework within which all query professionals operate.
Key Policy Areas to Address
Each policy area requires careful consideration of regulatory requirements, clinical workflow, and organizational risk tolerance. Policies should be reviewed and updated regularly to reflect changes in ICD-10-CM guidelines, AHA Coding Clinic advice, and organizational needs.
Escalation Policy
Facilities must develop a clear escalation policy that outlines the process, participants, time frames, and purpose of query escalation. The escalation process is not intended to direct or intimidate the recipient to elicit a specific response.
Unanswered or Unresolved Query
Query professional identifies that a query has not been answered within the established time frame or that the response does not provide the needed clarification.
Initial Escalation to Supervisor
Escalation begins with the direct supervisor or manager, who reviews the query for compliance and coordinates follow-up within defined time frames.
Physician Advisor or Medical Director
If unresolved, the matter is referred to a physician advisor, chief medical advisor, or other administrative professional with authority to facilitate resolution.
Compliance Department Review
For systemic or recurring issues, the compliance department applies the guidance in the Practice Brief to evaluate communications and identify areas requiring education or process improvement.
Query Technology
Technological advancements — including AI, Computer-Assisted Coding (CAC), and Computer-Assisted Physician Documentation (CAPD) — have significant potential to enhance query professional efficiency and improve documentation completeness. However, technology does not replace the judgment of the query professional.
Technology Standards & Compliance
QP Responsibility Remains
With the evolution of healthcare technology, it remains the responsibility of the query professional to distinguish between legitimate query opportunities and inappropriate triggers — and to recognize potential opportunities not identified by technology.
No Follow-Up Manual Queries
If a technology-driven query does not yield the desired response, it is inappropriate to send a follow-up manual query for the same diagnosis, condition, or procedure in the absence of new clinical indicators.
Same Compliance Standards Apply
Any technology-generated documentation query must follow all query compliance guidance discussed in this practice brief — including non-leading standards, clinical indicator inclusion, and appropriate answer option construction.
For additional guidance on the compliant use of technology, refer to the AHIMA/ACDIS Compliant CDI Technology Standards White Paper.
Sample Query Examples
The following examples illustrate compliant query construction across common clinical scenarios. Use these as a guide in developing queries — they are examples only. Always follow your organization's policies and procedures when developing actual queries. Clinical indicators shown are not all-inclusive.
Example #1: Clinical Validation Query
When a diagnosis is documented but appears to lack clinical support, clinical validation queries may take one of two compliant forms. Both options must be non-leading and include all relevant clinical indicators with sourcing.
Option 1 — Indicators First
Acute respiratory failure on H&P dated xx/xx and progress notes dated xx/xx and xx/xx.
Clinical Indicators: H&P indicates: Underlying pneumonia, respiratory rate 12, no accessory muscle usage, ABGs: pH 7.40, pCO2 36, pO2 75 on room air.
Based upon the clinical indicators below, please clarify the status of respiratory function:
- Acute respiratory failure ruled out
- Acute respiratory failure confirmed (please document additional supporting information or mitigating factors)
- Other explanation of clinical findings (please specify) ____
Option 2 — Question First
Please clarify the diagnosis related to the respiratory failure:
- Acute respiratory failure ruled out
- Acute respiratory failure confirmed (please document additional supporting information or mitigating factors)
- Other explanation of clinical findings (please specify) ____
Acute respiratory failure was documented on H&P dated xx/xx and progress notes dated xx/xx and xx/xx.
Clinical Indicators: H&P indicates: Underlying pneumonia, respiratory rate 12, no accessory muscle usage, ABGs: pH 7.40, pCO2 36, pO2 75 on room air.
Example #2: Prior Encounter Supporting Current Diagnosis
Documentation in the present and prior health records provides evidence to support the presence and staging of a condition documented in the current encounter.
Clinical Indicators: Progress note (mm/dd/year) indicates renal dosing applied to Metronidazole. Current H&P (mm/dd/year) states CKD, no stage documented. Previous encounter discharge summary (xx/xx) documents CKD Stage 4. Trending eGFR (x/xx, x/xx, x/xx) ranging 17–20 mL/min.
Please clarify the staging of the CKD:
- CKD, Stage 4
- Other explanation of clinical findings (please specify)
- Clinically undetermined
Example #3: Prior Record Supporting Further Specification
Evidence in a previous health record supports further specification of a currently documented condition.
Acute congestive heart failure was documented on progress note dated xx/xx.
Clinical Indicators: Echo from last week's office visit indicates ejection fraction of 35% and diastolic dysfunction.
Please further specify the diagnosis of heart failure:
- Acute systolic congestive heart failure
- Acute systolic and diastolic congestive heart failure (combined)
- Other explanation of clinical findings (please specify) ____
Example #4: Medically Evident Diagnosis
When a medical diagnosis is clinically evident from the health record but not explicitly stated by the provider, a query may be constructed as follows.
Clinical Indicators: Respiratory therapy (dated xx/xx) notes continuous home O2 at 2L/min, continued this admission. H&P (dated xx/xx) indicates history of COPD, GOLD Stage 4.
Please clarify the baseline respiratory function:
- Chronic respiratory failure
- Chronic respiratory insufficiency
- Other explanation of clinical findings (please specify) ____
Example #5: Cause-and-Effect Relationship
When the etiology of a documented condition is uncertain and clinical indicators suggest a plausible cause-and-effect relationship, a query may be structured as follows.
Clinical Indicators: H&P (dated xx/xx) states lung cancer with bone metastasis, currently undergoing chemotherapy. Pancytopenia was documented on progress note (dated xx/xx).
Please clarify the etiology of pancytopenia:
- Pancytopenia due to chemotherapy
- Pancytopenia due to other cause (please specify): ____
- Pancytopenia, etiology unknown
Frequently Asked Questions
The following Q&A addresses common questions raised by CDI and coding professionals regarding the application of the Guidelines for Achieving a Compliant Query Practice. These answers reflect the intent of the Practice Brief's authors and provide practical guidance for real-world scenarios.
FAQ: Roles, Definitions & Definitions of "Query"
Do Query Guidelines Apply to Utilization Review & Quality?
Yes. Many disciplines work with providers to clarify documentation — including utilization review, quality reporting, and physician advisors. If their activities meet the definition of a query, the Guidelines for Achieving a Compliant Query Practice apply. CDI/coding professionals are not the "query police" — organizational compliance departments should apply the guidance and implement auditing processes.
Can Definitions Be Included in a Query?
Yes — including diagnostic criteria or staging ranges (e.g., types of atrial fibrillation, CKD staging criteria) is common practice and not considered leading. The information should be provided without highlighting, bolding, or otherwise indicating a preferred answer choice.
Is a Query Response Alone Sufficient for Code Assignment?
If a compliant query has been properly answered and authenticated by a responsible provider and is part of the permanent health record, it is sufficient for code assignment. The response need not be repeated elsewhere in the health record. Organizations should define approved locations for query responses in policy.
FAQ: Formatting, Highlighting & Leading Queries
Is Using Quotation Marks in a Query Compliant?
Yes. Using quotation marks to identify information pulled directly from the health record — such as a provider statement or nursing assessment — is appropriate. All clinical indicator entries should be accompanied by sourcing within the medical record so the provider can independently verify the information if needed.
Is It Compliant to Highlight or Bold Information in a Query?
Best practice is not to highlight any information within the query that could be construed as leading. Highlighting should never be used within the answer option choices of a query under any circumstances.
Can a Query Be Non-Compliant Without Being Leading?
Yes. A query can be non-compliant even if it is not overtly leading. If the query lacks valid clinical indicators specific to the encounter, or does not support a more complete or accurate diagnosis, it fails the requirements of Section V of the Compliant Query Guidelines — regardless of whether it leads the provider toward a specific response.
FAQ: Yes/No Queries, "Unable to Determine" & Escalation
Is "Unable to Determine" Required in "Ruled In/Ruled Out" Queries?
Yes. A "ruled in / ruled out" query is essentially a Yes/No query. Per the brief, Yes/No queries must include "unable to determine." If the diagnosis has not been specifically documented, a multiple-choice query — following the guidance in the brief — is typically more appropriate than a Yes/No format.
What If a Non-Compliant Query Has Already Been Signed?
Organizations should maintain well-defined escalation policies guiding individuals on how to address and communicate circumstances where queries are identified as potentially non-compliant. If a provider signs a query to avoid conflict, this must be escalated appropriately — not accepted as a valid query response.
Should Providers Be Able to Indicate the Query Is Unnecessary?
The "other, please specify" option allows providers to clarify disagreement with the query's intent. Organizations may also include options such as "no further clarification is needed" to track this occurrence. A policy should be in place to address and analyze these responses for query improvement purposes.
FAQ: Prior Encounters & Subjective Interpretation
What Does "Subjective Interpretation by the QP" Mean?
The query professional should not insert diagnoses or offer personal interpretation into the body of the query. For example: if documentation shows a heart rate of 120, the clinical indicator should state "heart rate 120," not "tachycardia." If hemoglobin is 10 g/dL, the indicator should not say "anemia" — only the objective value. Interpretation is the provider's clinical role, not the QP's.
What Does "Mining" Prior Encounters Mean?
"Mining" is consulting health information from prior encounters without any guiding reason or focus from the current encounter. It is reviewing previous records to identify diagnoses or condition specificity that is not related to the present encounter. Organizations should develop policies defining when prior encounter review is appropriate and how far back records may be accessed.
Conclusion
Healthcare professionals who work alongside providers to ensure accuracy in health record documentation should follow established facility and organizational policies, processes, and procedures that are congruent with recognized professional guidelines.
This Practice Brief represents the joint efforts of AHIMA and ACDIS to provide ongoing guidance related to compliant querying. As healthcare delivery continues to evolve, future revisions to this Practice Brief will be required. Both healthcare organizations and payers should hold each other accountable to these standards — using these policies to evaluate query compliance and defend that compliance when challenged by denial trends or external review.
References
CMS Coding Guidance (2022)
ICD-10-CM Official Guidelines FY 2023
AHIMA Problem List Definition (2019)
AHIMA. "Definition, History, and Use of the Problem List." Journal of AHIMA 90, no. 7 (Jul-Aug 2019): 44–49.
Clinical Validation: The Next Level of CDI (2019)
AHA Coding Clinic (2014)
AHA Coding Clinic® for ICD-10-CM/PCS, First Quarter 2014.
Compliant CDI Technology Standards (2021)
AHIMA/ACDIS. Compliant CDI Technology Standards
AHIMA & ACDIS Resources
Inpatient Query Toolkit
AHIMA Inpatient Query Toolkit — A comprehensive guide to building compliant inpatient queries from scratch.
Outpatient Query Toolkit
AHIMA Outpatient Query Toolkit — Tailored guidance for outpatient CDI query development and compliance.
CDI Toolkit Beginners' Guide
Clinical Documentation Integrity (CDI) Toolkit Beginners' Guide (ahima.org) — An essential starting point for new CDI professionals.
Clinical Validation Practice Brief
Clinical Validation: The Next Level of CDI (January 2019 Update) — Deep guidance on clinical validation as a complement to the query process.
Authors
This Practice Brief was authored by a distinguished group of CDI, coding, and clinical professionals representing a broad range of expertise:
Sheri Blanchard
RN, MSN, FNP/BC, CCDS, CCS
Sharme Brodie
RN, CCDS, CCDS-O, CRC
Karen Carr
MS, BSN, RN, CCDS, CDIP
Tammy Combs
RN, MSN, CDIP, CCS, CNE
Keisha Downes
BSN, RN, CCDS, CCS
Dorene Hughes
MSN, RN, CCDS, CDIP, ACHS
Carole Liebner
RHIT, CDIP, CCS
Kay Piper
RHIA, CDIP, CCS
Melissa Potts
RN, BSN, CCDS, CDIP
Laurie Prescott
RN, MSN, CCDS, CCDS-O, CDIP, CRC
AGES Coding Tech — Part of JVAGES Health Care
AGES Coding Tech is a premier medical coding and clinical documentation training organization, part of JVAGES Health Care. We specialize in preparing healthcare professionals for compliant, high-quality careers in CDI, coding, and health information management — equipping learners with the skills and knowledge reflected in industry standards such as the AHIMA-ACDIS Practice Briefs.
Contact Us & Connect
📧 Email Us
📍 Visit Our Training Center
4th Floor, Shreyas Anish PVR North West Apartment, F-402A, Balaji Nagar, Kukatpally, Hyderabad, Telangana 500072
HR Contact Details
- H1 — Mrs. Dhanalakshmmi: +91-8015029971
- H2 — Mrs. Vandhana: +91-9063546650
- H3 — Mr. Vaibhav: +91-9390379206
- H4 — Mr. Surya: +91-8074468321
- H5 — Training Clarifications: +91-9043464563 / +91-8668066650
Guidelines for Achieving a Compliant Query Practice