A 62-year-old female with history of HTN, CAD, chronic cough and obesity is seen by her PCP. Which of the following treatment plans may result in a…

A query is warranted when clinical documentation is incomplete, conflicting, or ambiguous. In this scenario, the patient has risk factors for diabetes (obesity, HTN, CAD), but no documented diagnosis or suspicion of diabetes. The physician's order for a hemoglobin A1c (HbA1c) test, a primary tool for diagnosing and monitoring diabetes, serves as a strong clinical indicator for a potential underlying condition. A CDI specialist would issue a query to the provider to clarify the clinical significance of this test and document a potential diagnosis if appropriate, ensuring the medical record is complete and accurate.

A. A diagnostic chest x-ray is a logical and direct workup for a patient presenting with a chronic cough and does not create ambiguity.

B. A referral to a nutrition specialist is an appropriate treatment plan for a patient with a documented diagnosis of obesity.

D. Prescribing an ACE inhibitor is a standard, appropriate treatment for the patient's documented conditions of hypertension (HTN) and coronary artery disease (CAD).

1. Association of Clinical Documentation Integrity Specialists (ACDIS). (2019). Guidelines for Compliant Query Practice. This industry-standard brief outlines that a query is appropriate when clinical indicators suggest a diagnosis that is not documented. An unexplained lab order like an HbA1c is a classic example.

2. American Health Information Management Association (AHIMA). (2019). Guidelines for Achieving a Compliant Query Practice. This practice brief states, "The query should be initiated when there is conflicting, incomplete, or ambiguous documentation in the health record...or when clinical indicators suggest a diagnosis." (Section: "When to Query").