A comprehensive guide from AHIMA on maintaining integrity in healthcare documentation through proper querying techniques — ensuring accurate code assignment and compliant clinical communication.
What Is a Query?
Definition
A query is a communication tool used to clarify documentation in the health record for accurate code assignment. The desired outcome is an update to the health record that better reflects a practitioner's intent and clinical thought processes.
Purpose
The final coded diagnoses and procedures derived from health record documentation should accurately reflect the patient's episode of care. This practice brief augments and, where applicable, supersedes prior AHIMA guidance on queries.
All professionals are encouraged to adhere to these compliant querying guidelines regardless of credential, role, title, or technological tools used.
The Core Principle
In court, an attorney can't "lead" a witness. In hospitals, coders and clinical documentation specialists can't lead healthcare providers with queries. Appropriate etiquette must be followed when querying providers for additional health record information.
A proper query process ensures that appropriate documentation appears in the health record. Personnel performing the query function should focus on a compliant process and content reflective of appropriate clinical indicators.
When to Generate a Query
A query should be considered when the health record documentation meets any of the following conditions:
Conflicting or Incomplete
Documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent.
Unlinked Clinical Indicators
Describes clinical indicators without a definitive relationship to an underlying diagnosis.
Unrelated Findings
Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure.
Unvalidated Diagnosis
Provides a diagnosis without underlying clinical validation, or is unclear for present on admission (POA) indicator assignment.
Query Format Options
Open-Ended
Preferred format. Allows the provider to respond freely based on clinical judgment without being directed to a specific answer.
Multiple Choice
Acceptable under certain circumstances. Must include clinically significant options plus "clinically undetermined" and "other" for free text.
Yes/No
Acceptable in limited circumstances. Must also include "other," "clinically undetermined," and "not clinically significant" options.
What Makes a Query Leading vs. Nonleading?
A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. The justification — inclusion of relevant clinical indicators — is more important than the query format.
Query Example: Clarification for Specificity
Clinical Scenario
Obtunded patient admitted with three-day history of nausea and vomiting. CXR revealed right lower lobe (RLL) pneumonia. Clindamycin ordered.
Leading Query ❌
"Is the patient's pneumonia due to aspiration?"
Nonleading Query ✅
"Can the etiology of the patient's pneumonia be further specified? This obtunded patient had a history of nausea and vomiting prior to admission and is treated with clindamycin for RLL pneumonia. Based on the above, can the etiology be further specified? If so, please document the type/etiology in the progress notes."
Clinical Indicators: The Foundation of Every Query
All queries must be accompanied by the relevant clinical indicator(s) that show why a more complete or accurate diagnosis or procedure is requested. Clinical indicators should be derived from the specific medical record under review and the unique episode of care.
Although AHA's Coding Clinic for ICD-9-CM often references clinical indicators, it is not an authoritative source for establishing them. Clinical indicators supporting the query may include diagnostic findings, provider impressions, and other elements from the entire medical record.
Documenting Query Responses
Capture All Content
Best practice is to capture the content of both verbal and written queries, as well as any practitioner response, to account for documentation that might otherwise appear out of context.
Provide Clinical Rationale
If the practitioner documents a query response directly into the health record without supporting clinical information, they should provide clinical rationale (e.g., "Patient transfused four days ago due to acute blood loss anemia").
Maintain as Permanent Record
If the practitioner responds only on the query form, that form should become part of the permanent health record. Organizations not maintaining queries in the permanent record should keep copies as administrative business records.
Multiple Choice Query Requirements
Multiple choice query formats must include clinically significant and reasonable options as supported by clinical indicators in the health record. There may be only one reasonable option in some cases.
Clinically Supported Options
Providing a new diagnosis as an option — when supported by referenced clinical indicators — is not introducing new information.
Clinically Undetermined
Always include "clinically undetermined" and "other" to allow the provider to add free text.
Additional Options
"Not clinically significant" and "integral to" may be included on the query form if appropriate.
Yes/No Query: Permitted Circumstances
Substantiating a Diagnosis
Substantiating or further specifying a diagnosis already present in the health record (e.g., findings in pathology, radiology, and other diagnostic reports) with physician interpretation.
Cause and Effect Relationships
Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications (e.g., hypertension and congestive heart failure).
Resolving Conflicting Documentation
Resolving conflicting documentation from multiple practitioners. Also used for present on admission (POA) determinations.
Yes/No Query: Compliant Example 1
Clinical Scenario
In the impression of the pathology report, ovarian cancer is documented; however, only "ovarian mass" is documented in the final discharge statement by the provider.
Rationale
This yes/no query involves confirming a diagnosis already present as an interpretation of a pathology specimen in the health record.
Query
"Do you agree with the pathology report specifying the 'ovarian mass' as an 'ovarian cancer'? Please document your response in the health record or below."
Yes _____ No _____ Other _____ Clinically Undetermined _____
Name: _____ Date: _____
Yes/No Query: Compliant Example 2
Clinical Scenario
Consulting pulmonologist documents pneumonia as an impression based on the chest X-ray. However, the attending physician documents bronchitis throughout the record, including in the discharge summary.
Rationale
This is an example of a yes/no query resolving conflicting practitioner documentation.
Query
"Do you agree with the pulmonologist's impression that the patient has pneumonia? Please document your response in the health record or below."
Yes _____ No _____ Other _____ Clinically Undetermined _____
Name: _____ Date: _____
Verbal Queries: Same Standards Apply
Verbal queries should contain the same clinical indicators and follow the same format as written queries to ensure compliance and consistency in policy and process. Documentation may be condensed but must identify the clinical indicators and the actual question posed.
Verbal queries should be documented at the time of the discussion or immediately following. A standard format should be used:
"Spoke with Dr. X regarding the documentation of _(condition/procedure)_ based upon the clinical indicator(s) found in the health record _(list what was found and where)_."
Clinical Validation & External Audits
Expanded Audit Focus
The focus of external audits has expanded to include clinical validation review. CMS has instructed coders to "refer to the Coding Clinic guidelines and query the physician when clinical validation is required."
Unsupported Diagnoses
When a practitioner documents a diagnosis not supported by clinical indicators, a query should be generated to address the conflict, or the conflict addressed through the facility's escalation policy.
Escalation Policy
CMS recommends each facility develop an escalation policy for unanswered queries. This may include referral to a physician advisor, chief medical officer, or other administrative personnel.
Query Example: Documented Conditions Without Clinical Indicators
Clinical Scenario 1
Laboratory finding of serum sodium of 120 mmol/L and the attending physician documents hypernatremia in the final diagnostic statement.
Query
"Please review the laboratory section of the present record to confirm your discharge diagnosis of hypernatremia. Laboratory findings indicate a serum sodium of 120 mmol/L."
Clinical Scenario 2
Four-year-old child sustains a cautery injury to upper lip during maxillofacial surgery. Silvadene and dressing applied; plastic surgery consulted. Surgeon documented "no intraoperative complications."
Query
"Please review the operative note notation of 'a cautery lesion to the upper lip,' subsequent treatment with Silvadene and clarify your documentation of 'no intraoperative complications.'"
Query Retention Policies
Each organization should develop internal policies regarding query retention. Ideally, a practitioner's response is documented in the health record — including progress notes or discharge summary. If the record has been completed, an addendum should be timely, bear the current date, time, and reason, and be electronically signed.
Key Retention Policy Requirements
Statutory Compliance
Organizational policies must address query retention consistent with statutory or regulatory guidelines, specifying whether the query is part of the permanent health record or a separate business record.
Indefinite Retention
It may be necessary to retain the query indefinitely if it contains information not documented in the health record. Auditors may request copies to validate query wording.
Trend Analysis
An important consideration in query retention is the ability to collect data for trend analysis, providing opportunity for process improvement and identification of educational needs.
Open-Ended Query Example
A patient is admitted with pneumonia. The admitting H&P reveals WBC of 14,000; respiratory rate of 24; temperature of 102°F; heart rate of 120; hypotension; and altered mental status. IV antibiotic and IV fluid resuscitation administered.
Leading ❌
"The patient has elevated WBCs, tachycardia, and is given an IV antibiotic for Pseudomonas cultured from the blood. Are you treating for sepsis?"
Nonleading ✅
"Based on your clinical judgment, can you provide a diagnosis representing: WBC 14,000; respiratory rate 24; temperature 102°F; heart rate 120; hypotension; altered mental status; IV antibiotic; IV fluid resuscitation? Please document the condition and causative organism (if known) in the medical record."
Multiple Choice Query Example
A patient is admitted for a right hip fracture. H&P notes chronic congestive heart failure. Recent echocardiogram showed left ventricular ejection fraction (EF) of 25 percent. Home medications include metoprolol XL, lisinopril, and Lasix.
Leading ❌
"Please document if you agree the patient has chronic diastolic heart failure."
Nonleading ✅
"Given chronic congestive heart failure and EF of 25%, can the chronic heart failure be further specified as: Chronic systolic heart failure / Chronic diastolic heart failure / Chronic systolic and diastolic heart failure / Some other type / Undetermined?"
Appendix A: Yes/No Compliant Examples
Example 1: Post-Surgical Cellulitis
Patient admitted with cellulitis around a recent operative wound. Query: "Is the cellulitis due to or the result of the surgical procedure?" — This involves a documented condition potentially resulting from a procedure.
Example 2: Systolic CHF Specificity
Congestive heart failure documented; echocardiogram shows systolic dysfunction; patient on lisinopril, Lasix, Lanoxin. Query asks if CHF can be further specified as systolic — determining specificity of a documented condition.
Example 3: Serosal Injury During Surgery
Serosal injury to stomach noted and repaired during abdominal mass removal. Query asks if this was a complication, integral to the procedure, or not clinically significant — determining clinical significance of a procedural finding.
Non-Compliant Query Examples
Example 1: Edema & Malnutrition
Bilateral lower extremity edema noted on admission with no other clinical indicators for malnutrition. A yes/no query asking if edema is "diagnostic of malnutrition" is non-compliant. An open-ended or multiple choice query should be used instead.
Example 2: Anemia Specificity
Patient with GI bleed, hemoglobin drop from 12 to 7.5 g/dL, two units transfused. A yes/no query asking if "anemia" can be specified as "acute blood loss anemia" is non-compliant — a multiple choice or open-ended query is required.
Example 3: CAUTI & Impact Disclosure
A query that explains the impact of a diagnosis on physician and hospital profiles is inappropriate. It questions clinical judgment and may be more appropriate as part of an escalation policy and/or physician education.
Always Follow Best Practices
Healthcare professionals working alongside practitioners to ensure accuracy in health record documentation should follow established facility policies congruent with recognized professional guidelines. This practice brief represents the joint efforts of AHIMA and the Association for Clinical Documentation Improvement Specialists.
As healthcare delivery continues to evolve, future revisions to these guidelines are expected. The term "possible" is a very broad qualifier and its use in a query is discouraged.
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References
AHA Coding Clinic
AHA. Coding Clinic, Second Quarter, 2012, p. 21.
AHIMA EHR Amendments
AHIMA. "Amendments in the Electronic Health Record." AHIMA Toolkit. Published August 15, 2012.
AHIMA CDI Guidance
AHIMA. "Guidance for Clinical Documentation Improvement Programs." Journal of AHIMA 81, no.5 (May 2010): 45–50.
AHIMA Query Management
AHIMA. "Managing an Effective Query Process." Journal of AHIMA 79, no.10 (October 2008): 83–88.
CMS Newsletter
Centers for Medicare and Medicaid Services. "Medicare Quarterly Provider Compliance Newsletter." Volume 1, Issue 4. July 2011.
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Guidelines for Achieving a Compliant Query Practice