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

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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?

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

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?

Accepted Answer

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

Answer

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.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

FREE CCDS Compliant Query Formulation Questions and Answers