review] Which of the following are appropriate clinical indicators to support a query related to alcohol dependency in remission?

A compliant query for "alcohol dependency in remission" requires clinical indicators that support both a history of dependence and the current remission status. A documented history of excessive alcohol use establishes the past condition. The patient's current and active participation in a recovery program, such as attending Alcoholics Anonymous (AA) meetings, is a strong clinical indicator that they are actively maintaining sobriety, which supports the "in remission" specifier. Together, these indicators provide a solid foundation for a query to the provider for diagnostic clarification.

A. Cirrhosis and elevated liver enzymes are not specific to alcohol dependence and can have other etiologies; they do not confirm the "in remission" status.

C. Admitting to occasional social drinking is inconsistent with the definition of "in remission" for alcohol dependence, which requires sustained abstinence.

D. Nausea, vomiting, and a distended abdomen are non-specific symptoms that do not clearly point to a history of alcohol dependence or a current state of remission.

1. American Health Information Management Association & Association of Clinical Documentation Integrity Specialists. (2019). Guidelines for Achieving a Compliant Query Practice (2019 Update). Journal of AHIMA, 90(9), 40-43. (This brief states queries must be supported by clinical indicators in the health record).

2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Section on Substance-Related and Addictive Disorders specifies remission criteria (e.g., early or sustained remission) based on the absence of criteria for the use disorder.

3. Poe, B. (Ed.). (2021). The CCDS-O Exam Study Guide (2nd ed.). ACDIS. Chapter 5, "Querying and Provider Engagement," p. 81, emphasizes that queries must be based on clinical indicators present in the chart.