FREE CCDS Compliant Query Formulation Questions and Answers

Question 1

A CDS reviews a record with clinical indicators of sepsis (fever, tachycardia, leukocytosis, and a positive blood culture) but the physician has only documented 'UTI'.
Which query statement is the most compliant?

Accepted Answer

Based on the documented fever, tachycardia, leukocytosis, and positive blood culture, can you please clarify a diagnosis that represents these findings?

Answer

Do you agree the patient has sepsis secondary to UTI based on the fever, tachycardia, and positive blood culture?

Answer

Please document sepsis as it is clearly supported by the clinical evidence in the chart.

Answer

Per sepsis-3 criteria, this patient meets the definition. Please clarify the diagnosis.

Question 2

When is a 'Yes/No' query format considered non-compliant?

Accepted Answer

When asking the physician to establish a new diagnosis based on clinical indicators.

Answer

When clarifying the acuity of a condition already documented (e.g., 'Is the heart failure acute?')

Answer

When attempting to link two documented conditions (e.g., 'Is the hyponatremia due to the patient's SIADH?')

Answer

When confirming if a condition was present on admission.

Question 3

What is the primary risk of using 'leading' language in a physician query?

Accepted Answer

It can be seen by auditors as introducing information to artificially inflate reimbursement.

Answer

It may confuse the physician, leading to an incorrect response.

Answer

It is against hospital policy but has no external regulatory implications.

Answer

It often results in lower query response rates from providers.

Question 4

A physician consistently documents 'urosepsis' without specifying if the patient has sepsis. What is the best long-term educational strategy for the CDS?

Accepted Answer

Provide the physician with a brief educational tip sheet explaining the clinical and coding definitions of sepsis and how 'urosepsis' is ambiguous.

Answer

Continue to send a query on every case until the physician changes their behavior.

Answer

Report the physician to the Chief Medical Officer for non-compliant documentation.

Answer

Ask the coding department to always code 'urosepsis' to the UTI code.

Question 5

A CDS has sent two compliant, well-supported queries to a physician regarding the etiology of a patient's anemia, but has received no response. What is the most appropriate next step according to standard CDI practice?

Accepted Answer

Follow the department's escalation policy, which may involve notifying the CDI manager or physician advisor.

Answer

Close the query as 'no response' and move on to the next chart.

Answer

Confront the physician in the hallway and demand an answer.

Answer

Add a note in the chart stating 'Physician refused to clarify anemia etiology'.

Question 6

What is a critical requirement for documenting a verbal query?

Accepted Answer

The CDS must document the question, clinical indicators, and the physician's response in the health record for the physician to sign.

Answer

The CDS must send a follow-up email to the physician summarizing the conversation.

Answer

The CDS must record the conversation on a mobile device for future reference.

Answer

The CDS should simply remember the conversation and inform the coder of the physician's answer.