Purpose of the Physician Query
A physician query is a formal communication tool used by coding and CDI professionals to clarify ambiguous, incomplete, or conflicting documentation in the health record. Queries must be constructed in a way that seeks clarification without leading the provider to a predetermined answer.
Compliant Query Formats
- Open-ended queries: ask the provider to describe the clinical picture in their own words, most appropriate when multiple clinical indicators are present without documentation of a specific diagnosis
- Multiple-choice queries: offer a reasonable range of clinically supported options, always including choices such as "other," "clinically undetermined," or "not clinically significant"
- Queries must never suggest a diagnosis with higher reimbursement unless clinical indicators genuinely support it
When to Query
A query is appropriate when documentation is conflicting between providers, when clinical indicators suggest a condition not documented, when a diagnosis is documented without a clear underlying cause, or when specificity is needed to assign the most accurate code. Queries should never be generated simply to increase reimbursement without clinical support.
Query Content Standards
- Present clinical indicators from the current encounter that prompted the query
- Avoid providing a diagnosis and simply asking the provider to confirm it, unless supported by robust clinical evidence and framed as one option among several
- Document the query as a permanent part of the health record according to organizational policy
- Route the query to the treating provider best positioned to answer, not simply the most accessible one
Verbal Queries
Verbal queries are permitted but should be documented consistently with the same standards as written queries, including the clinical indicators discussed and the provider's response, to preserve compliance and auditability.
Compliance Risk of Poor Query Practice
Leading queries that suggest a specific, higher-weighted diagnosis without adequate clinical support can be viewed as fraudulent upcoding during an audit. Query compliance is therefore both a documentation quality issue and a legal risk management issue.
Exam Tip
Be able to identify whether a sample query is compliant or leading, and understand why multiple-choice queries must always include a "clinically undetermined" or similar neutral option.