When compliantly querying providers, CDI specialists or HIM/coding professionals may

Compliant physician queries present clinical evidence from the current encounter to prompt the provider for clarification or additional specificity. Offering a new diagnosis as an option in a multiple-choice format is acceptable if it is reasonably supported by the health record's clinical indicators. This practice allows the provider to use their professional judgment to select the most accurate diagnosis based on the evidence presented, without being led to a specific conclusion. The key is that the option must be supported by evidence within the current record.

A. Queries must be based on clinical indicators from the current encounter, not solely on past medical history, to be compliant and clinically valid.

B. Identifying diagnoses as HCCs is considered leading because it links clinical documentation to financial reimbursement, which is non-compliant query practice.

D. A compliant query must include the specific clinical indicators that raise the question, providing context for the provider to make an informed decision.

1. Association of Clinical Documentation Integrity Specialists (ACDIS) & American Health Information Management Association (AHIMA). (2019). Guidelines for Achieving a Compliant Query Practice. Section: "Query Format," pp. 6-7. This brief explicitly states that multiple-choice queries can include options for additional diagnoses not previously documented, as long as they are supported by clinical indicators.

2. ACDIS. (2022). Code of Ethics. Principle 2. This principle requires CDI professionals to facilitate accurate and complete documentation and not lead providers to a specific diagnosis. Omitting indicators (D) or highlighting HCCs (B) would violate this.