RE: RE:[EXTERNAL] Question Regarding Criteria and Clinical Judgment
Most recent Best Practice jointly published by AHIMA and ACDIS states a query should be used when a diagnosis is stated but clinical criteria is lacking...see bullet #4.
When and How to Query
The generation of a query should be considered when the health record documentation:
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
When and How to Query
The generation of a query should be considered when the health record documentation:
•Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
•Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
•Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
•Provides a diagnosis without underlying clinical validation
•Is unclear for present on admission indicator assignment
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org