Reviewing and analyzing physician query content on a regular basis assists in identifying gaps in skills and knowledge of the clinical documentation integrity practitioners (CDIPs) and the providers. By evaluating the quality, accuracy, appropriateness, and effectiveness of the queries, the CDIPs can identify areas of improvement, education, and feedback for themselves and the providers.  Reviewing and analyzing physician query content can also help to ensure compliance with industry standards and best practices, as well as to monitor query outcomes and trends 2   References :  1 : https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf  2 : https://my.ahima.org/store/product?id=67077

A transbronchial biopsy is a procedure that involves obtaining tissue samples from the alveoli (air sacs) of the lungs through a bronchoscope. A pathology report documenting alveolar tissue is a clinical documentation element that supports a transbronchial biopsy, as it confirms the source and nature of the tissue sample.

References : AHIMA. “CDIP Exam Preparation.” AHIMA Press, Chicago, IL, 2017: 55-56.

According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment 1 .  A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query 1 .  A query should also provide multiple choice answer options that are supported by clinical indicators and include a non- leading query statement 2 . In this case, the patient has a large right lung pleural effusion related to lung cancer stage II, which is documented multiple times. However, the documentation does not specify whether the pleural effusion is malignant or not.  A malignant pleural effusion is a condition where cancer cells spread to the pleural space and cause fluid accumulation 3 .  A malignant pleural effusion is a major complication or comorbidity (MCC) that affects the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality scores of the hospital 4 . Therefore, a post discharge query opportunity should be sent to the physician to clarify whether the pleural effusion is malignant or not, based on the clinical indicators such as chest x-ray, thoracentesis, and fluid analysis. The query should provide answer options such as malignant pleural effusion, non-malignant pleural effusion, unable to determine, or other. The other options are not correct because they either do not affect the SOI/ROM of the patient (A and C), or they do not address the specificity of the diagnosis (D).  References :

CDIP Exam Preparation Guide - AHIMA

Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

Malignant Pleural Effusion: Symptoms, Causes, Diagnosis & Treatment

Q & A: Coding for malignant pleural effusions | ACDIS

One of the best practices for writing a compliant query is to include all relevant clinical indicators from the health record that support the need for clarification and the query options. Clinical indicators are objective and measurable signs, symptoms, laboratory results, diagnostic test results, medications, treatments, and other documented findings that are related to a specific diagnosis or condition. Including clinical indicators helps to provide the rationale for the query, avoid leading or suggesting a desired response, and ensure that the query is based on evidence and not assumptions. The other options are not best practices for writing a compliant query. Directing the physician to a specific diagnosis is leading and noncompliant. Using the term “possible” to describe a condition or diagnosis when uncertain if the diagnosis is present is vague and imprecise. Using a yes/no query format for specificity of a diagnosis is discouraged, as it limits the provider’s choices and may not capture the true clinical picture.

According to the AHIMA CDIP Exam Preparation Guide, a modifier is a two-digit numeric or alphanumeric code that may be used in CPT and/or HCPCS codes to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code 1 .  One of the reasons to use a modifier is to indicate that a service or procedure was increased or reduced in comparison to the usual service or procedure 2 .  For example, modifier 22 can be used to report increased procedural services that require substantially greater time, effort, or complexity than the typical service 3 . The other options are not correct because they do not reflect the purpose of using modifiers. A service or procedure performed in its entirety does not need a modifier, as it is assumed to be the standard service or procedure. A service or procedure resulting in expected outcomes does not affect the coding or reimbursement of the service or procedure. A service or procedure performed by one provider may need a modifier depending on the type of provider, the place of service, and the payer rules, but it is not a general reason to use a modifier.  References :

CDIP Exam Preparation Guide - AHIMA

Modifiers: A Guide for Health Care Professionals - CMS

CPT® Modifiers: 22 Increased Procedural Services | AAPC

According to the AHIMA-ACDIS Practice Brief, a query escalation policy should describe how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, the department director, or administration with defined actions as to the responsibilities at each level.  The policies should reflect a method of response that can realistically occur for the organization 1 .  In this case, since the attending physician has not responded to the query in an appropriate time frame, the CDIP should escalate the issue to the medical staff leadership, such as the chief medical officer, the department chair, or the physician advisor, who can facilitate communication and education with the attending physician and ensure documentation integrity and compliance 1 .

References :

Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA 1

Inconsistent clinically relevant queries may make physicians lose respect for CDI efforts and disengage because they may perceive them as irrelevant, redundant, or contradictory. Clinically relevant queries are those that affect the quality of care, patient safety, severity of illness, risk of mortality, or reimbursement. Inconsistent queries may result from lack of standardization, conflicting guidelines, poor communication, or lack of clinical validation.  To avoid inconsistency, CDI practitioners should follow best practices such as using evidence-based criteria, adhering to query policies and procedures, collaborating with coding and quality staff, and seeking feedback from physicians and physician advisors  2 .

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  136  3   2 : Proactive CDI: Tackling the Problem of Physician Engagement  4

According to the CPT code description, 61154 is the appropriate code for a burr hole procedure for evacuation of a subdural hematoma.  A burr hole is a small hole made in the skull with a surgical drill to access the brain or its coverings 2 .  A subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, which are two of the three layers that cover the brain 3 . The evacuation of the hematoma involves removing the clot and relieving the pressure on the brain.  The other codes are not applicable for this procedure because they describe different methods of access (twist drill hole) or different purposes (biopsy or puncture) 4 .

References :

CDI Week 2020 Q & A: CDI and key performance indicators 1

Mayo Clinic: Burr hole 2

MedlinePlus: Subdural hematoma 3

CPT Code Book 2023 4

A query should be generated when the documentation is conflicting, meaning that there is contradictory or inconsistent information in the medical record that may affect the accuracy of coding, quality reporting, or reimbursement. For example, if the documentation in the progress notes differs from the documentation in the discharge summary, or if different providers document different diagnoses or procedures for the same patient, a query may be needed to resolve the discrepancy and obtain clarification from the source of the documentation. A query should not be generated when the documentation is legible, consistent, or complete, as these are desirable characteristics of documentation that do not require further clarification or verification.

References :

CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)

Accurate Documentation is Essential – Knowing When to Query your Providers 1