Querying Sepsis Without Leading
By Robin Sewell, CDIP, CCS, CIC, CPC, CCDS
Every so often a query crosses our desk that isn’t leading, isn’t vague, and isn’t technically non-compliant; it’s just too much. Too many findings crammed into one question, redundant phrasing irrelevant to the query purpose, and answer options that muddy rather than clarify the actual question.
We call this query bloat, and it’s just as damaging to a compliant, clinically meaningful query as leading language is.
The Scenario: Everything and the Kitchen Sink
A recent query asked the provider to clarify “any clinical significance” for a bundled list of risk factors, clinical indicators, and treatments with options ranging from “clinically insignificant” to “represents metabolic encephalopathy” to “represents baseline dementia only.”
The patient: an elderly woman with dementia, admitted for weakness and a UTI, with mental status that fluctuated throughout the stay against a baseline already documented as “typically disoriented.”
The Original Query
Clarification of Clinical or Diagnostic Findings
Dear Dr.,
Based on your medical judgment, can you further clarify any clinical significance for the risk factors, clinical indicators, and treatments below:
☐ Risk factors, clinical indicators, and treatments below are clinically insignificant
☐ Risk factors, clinical indicators, and treatments below represent metabolic encephalopathy
☐ Risk factors, clinical indicators, and treatments below represent patient baseline confusion and is dementia only
☐ Other (please specify): ___________
☒ Clinically unable to determine / Unknown
Female patient, 90+, with pertinent history of dementia, atrial fibrillation, stated chronic renal failure, HTN, IDDM, depression, HLD, and GERD, brought in from home. Patient is admitted for generalized weakness and UTI.
Clinical Indicators:
ED Note: Independently ambulatory at baseline and is typically disoriented at baseline according to her three family members present.
— Arrival to the ED she was unable to rise and walk or transfer on her own.
— PSYCHIATRIC: Normal mood and affect. Calm, cooperative. She is not oriented to the year or month which is baseline per the family.
Hosp Day 1: Remains mildly confused but is able to state she is at the hospital and believes it is a different month. She was awake when checked overnight and reported sleepiness but has not slept yet.
Hosp Day 2: She does have a history of dementia; however, they feel it was worsening.
— NEUROLOGIC: Alert and oriented x 3, GCS 15, normal mentation and speech. Moves all extremities x 4 without motor or sensory deficit.
Hosp Day 3: She was found to have a urinary tract infection and was started on Rocephin and admitted here. Her mental status has cleared, but she still continues to be quite weak. She could not participate in therapy yesterday but did participate somewhat this morning.
Treatment:
Rocephin 1 g, 100 mL/hr, IV Piggyback, Daily
What Went Wrong
Asking whether a list of risk factors and treatments “represents” a diagnosis is like asking whether a grocery list “represents” dinner. The question remains: what is being cooked?
The Kitchen Sink: Per the Query Practice Brief, risk factors and treatments aren’t separate from clinical indicators. They are clinical indicators. Throwing them together amid the clinical question blurred and bloated the intent of the query. In fact, there is no reason to include risk factors as these are general findings that can point to a variety of conditions and doesn’t necessarily mean the condition is present. The query should include only relevant clinical indicators that support a vague, incomplete, or missing diagnosis.
The False Choice: “Clinically insignificant,” asks whether something matters at all. If the provider selected that option, then how would they reconcile it with an actual diagnosis? How does that selection bring clarity to the health record and support accurate coding?
The Missed Boat: The golden opportunity to ask one definable question: What is the significance (if any) of acute confusion in a patient with an infection and underlying dementia?
A Tighter Version of the Same Query
Dear Dr,
Please clarify the etiology of the patient’s mental status changes during this admission:
☐ Metabolic encephalopathy (e.g., related to infection)
☐ Baseline dementia, no acute change
☐ Other (please specify): ___________
☐ Clinically unable to determine
Clinical Indicators:
ED Note: … typically disoriented at baseline according to her three family members present…. PSYCHIATRIC: … She is not oriented to the year or month which is baseline per the family.
Hosp Day 1: Remains mildly confused but can state she is at the hospital and believes it is a different month…
Hosp Day 2: She does have a history of dementia; however, they feel it was worsened… NEUROLOGIC: Alert and oriented x 3, GCS 15, normal mentation and speech.
Hosp Day 3: She was found to have a urinary tract infection and was started on Rocephin and admitted here. Her mental status has cleared…
Same clinical scenario, same underlying uncertainty but now the provider is being asked one identifiable question supported by the indicators that actually bear on it, with options that are genuine, mutually exclusive alternatives.
Query IQ Tip
Before a query goes out, ask: could I state, in one sentence, the single clinical question this is asking? If the answer requires an “and,” or the options require the provider to compare apples to oranges, it’s not a sharp query — it’s a bloated one.
The Takeaway
This is the discipline Brundage Group builds into every revenue integrity review. Feedback helps your CDI and Coding teams grow their skills and better engage providers through concise, focused queries that matter. If your queries are getting flagged, going unanswered, or just not landing with providers, that’s revenue sitting exposed. Let’s talk about what a sharper approach looks like for your team.
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Clarity isn’t just good practice; it is denial prevention.
