A CDI specialist identifies an opportunity to clarify a patient’s BMI. The CDI specialist leaves a query within the medical record for the ancillary…

A prospective query is initiated prior to or at the time of a patient encounter. In this scenario, the CDI specialist identifies a documentation opportunity and places the query for the ancillary team to address during the upcoming visit. This pre-encounter or point-of-service review aligns with the definition of a prospective review process, which aims to capture accurate documentation concurrently with care delivery in the outpatient setting.

A. Retrospective queries occur after the encounter is completed and billed, reviewing documentation post-discharge or post-visit.

B. Concurrent queries typically refer to reviews conducted during a multi-day inpatient hospital stay, not for a single outpatient visit.

D. Prebill review is a type of retrospective review that occurs after the encounter is complete but before the final bill is submitted.

1. Association of Clinical Documentation Integrity Specialists (ACDIS). (2022). CCDS-O Certification Exam Candidate Handbook. Page 6, Domain 1: Clinical & Coding Practice. "Prospective (pre-encounter) review... Concurrent (point-of-service) review..."

2. ACDIS & AHIMA. (2019). Guidelines for Compliant Query Practice: 2019 Update. Journal of AHIMA, 90(4), page 3. "Prospective queries are... presented to the provider before or at the time of the encounter."