Free CCDS Compliant Query Formulation Questions and Answers 1 — 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?
- Do you agree the patient has sepsis secondary to UTI based on the fever, tachycardia, and positive blood culture?
- Based on the documented fever, tachycardia, leukocytosis, and positive blood culture, can you please clarify a diagnosis that represents these findings? (Correct answer)
- Please document sepsis as it is clearly supported by the clinical evidence in the chart.
- Per sepsis-3 criteria, this patient meets the definition. Please clarify the diagnosis.
Correct answer: Based on the documented fever, tachycardia, leukocytosis, and positive blood culture, can you please clarify a diagnosis that represents these findings?
This query is compliant because it presents the objective clinical indicators from the record and asks the physician to provide a diagnosis based on their professional judgment without leading them to a specific answer. Options A and C are leading, and option B introduces information not present in the scenario.
Question 2: When is a 'Yes/No' query format considered non-compliant?
- When clarifying the acuity of a condition already documented (e.g., 'Is the heart failure acute?')
- When attempting to link two documented conditions (e.g., 'Is the hyponatremia due to the patient's SIADH?')
- When asking the physician to establish a new diagnosis based on clinical indicators. (Correct answer)
- When confirming if a condition was present on admission.
Correct answer: When asking the physician to establish a new diagnosis based on clinical indicators.
A 'Yes/No' query is non-compliant when it is used to establish a new diagnosis that has not been previously mentioned by the provider. This format can be perceived as leading the physician. It is best used for clarifying details of an already documented condition, such as acuity or linkage.
Question 3: What is the primary risk of using 'leading' language in a physician query?
- It may confuse the physician, leading to an incorrect response.
- It can be seen by auditors as introducing information to artificially inflate reimbursement. (Correct answer)
- It is against hospital policy but has no external regulatory implications.
- It often results in lower query response rates from providers.
Correct answer: It can be seen by auditors as introducing information to artificially inflate reimbursement.
Leading queries can be interpreted as introducing new information or influencing the physician's response, which could be viewed as evidence of a false claim by auditors. This undermines the integrity of the health record and can have significant legal and financial repercussions.
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?
- Continue to send a query on every case until the physician changes their behavior.
- Report the physician to the Chief Medical Officer for non-compliant documentation.
- Provide the physician with a brief educational tip sheet explaining the clinical and coding definitions of sepsis and how 'urosepsis' is ambiguous. (Correct answer)
- Ask the coding department to always code 'urosepsis' to the UTI code.
Correct answer: Provide the physician with a brief educational tip sheet explaining the clinical and coding definitions of sepsis and how 'urosepsis' is ambiguous.
Providing a brief, evidence-based educational tip sheet or a face-to-face conversation explains the 'why' behind the need for specific documentation. It addresses the root cause of the documentation issue in a collaborative way, rather than just repeatedly querying the same issue.
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?
- Close the query as 'no response' and move on to the next chart.
- Follow the department's escalation policy, which may involve notifying the CDI manager or physician advisor. (Correct answer)
- Confront the physician in the hallway and demand an answer.
- Add a note in the chart stating 'Physician refused to clarify anemia etiology'.
Correct answer: Follow the department's escalation policy, which may involve notifying the CDI manager or physician advisor.
A formal escalation process ensures that important documentation gaps are addressed while maintaining a professional and standardized approach. This usually involves a physician advisor who can engage the non-responsive physician in a peer-to-peer conversation.
Question 6: What is a critical requirement for documenting a verbal query?
- The CDS must send a follow-up email to the physician summarizing the conversation.
- The CDS must document the question, clinical indicators, and the physician's response in the health record for the physician to sign. (Correct answer)
- The CDS must record the conversation on a mobile device for future reference.
- The CDS should simply remember the conversation and inform the coder of the physician's answer.
Correct answer: The CDS must document the question, clinical indicators, and the physician's response in the health record for the physician to sign.
For a verbal interaction to be considered a compliant query, it must be documented in the permanent health record. This documentation should include the question asked, the clinical indicators discussed, the physician's response, and the date/time, followed by the physician's signature or attestation.
Free CCDS Compliant Query Formulation Questions and Answers 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?