Query Tip: Avoiding a Leading Query – Introduction of a New Diagnosis

by | Apr 23, 2018 | Beth Martilik, Education, Query Tip | 0 comments

Beth Martilik​, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador Beth Martilik,​ MA, RHIA, CDIP, CCS
Assistant Director of Education
AHIMA Approved ICD‑10 Trainer and Ambassador

“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…”

“…providing a new diagnosis as an option in a multiple choice list-as supported and substantiated by referenced clinical indicators from the health record-is not introducing new information…” Guidelines for Achieving a Compliant Query Practice (2016)

One way a physician query would be considered leading is by the introduction of a new diagnosis in the query. This creates a difficult situation for a coder when the clinical information in the record supports a specific diagnosis, but the physician fails to give the diagnosis. How is a coder to write a nonleading query in this situation?

The introduction of a new diagnosis is allowed as an option for response provided the clinical indicators clearly support that diagnosis. Options for response give a range of choices, any of which must be supported by the physician’s own documentation. The actual query question should not be the place to introduce a new diagnosis as this is guiding the physician to only one possible response.

 

 

The information contained in this query advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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