Query IQ: Beware of the Sin of Omission

Avoid denials with compliant, evidence-based queries. Learn from a real sepsis case when clinical indicators don’t support the diagnosis.

When Queries Lead to DRG Downgrades

By Robin Sewell, CCS, CDIP, CPC, CIC, CCDS-O

In Clinical Documentation Integrity (CDI), there is an uncomfortable truth we rarely acknowledge openly: sometimes the right query results in a lower-paying DRG. And that is not just acceptable; it is ethically the right thing to do. Compliant querying means clarifying ambiguous documentation within the health record regardless of the impact on revenue. Especially if querying can prevent future denials.

We’ve all felt the internal tug-of-war when a query might reduce reimbursement. It’s the moment when Adam Sandler’s famous Waterboy quote creeps into the back of your mind: “What Mama don’t know won’t hurt her.” The line implies the coder or CDI professional can just look the other way—because who can say for certain that they saw the query opportunity and chose not to act?

However, in the world of compliant CDI practice, this mindset is the textbook definition of a sin of omission.

Ethical CDI requires balance if we query when it increases reimbursement; we must also query when it can reduce reimbursement as well. Think of it as a compliance win.

Anything less is selective integrity, and payors will absolutely catch it. And when they do? They’ll downgrade the case for you, on the grounds that a query should have been issued.

Catheter-associated infections provide a prime example. A catheter-associated UTI with sepsis as a secondary diagnosis often results in a higher-paying DRG. Because of this, CDI specialists commonly query for a potential CAUTI when the clinical indicators support it. Occasionally, however, the confirmed catheter associated infection results in a downgrade of the DRG. Here is a recent example.

Case Example: A Perfect Setup for a Sin of Omission

Patient: 67-year-old male

Past Medical History: CKD III, type II diabetes, COPD, CAD s/p CABG, neurogenic bladder with chronic suprapubic catheter

Admitted For: Candidal sepsis due to UTI

H&P Notes:

“Fungal UTI, suprapubic catheter changed in the emergency department.”

The relevant clinical indicators are all present:

Chronic suprapubic catheter

Fungal UTI on admission

Sepsis due to fungal UTI

Catheter manipulation/change in ED

These findings support issuing a query for possible catheter-associated UTI (and associated sepsis).

And here’s where the discomfort sets in:

If confirmed by the provider, the case would require sequencing the complication code as principal diagnosis resulting in a DRG payment decrease of over $800.

Here’s how it works:

Before a Query	After a Query
DRG 871 Sepsis w/o vent w/MCC	DRG 862 Postop Infections w/MCC
PDX B37.7 Candidal Sepsis	PDX T83510A (infection and inflammatory reaction due to cystostomy catheter, initial encounter)
SDX I50.31Acute diastolic heart failure	SDX #1 B37.7 Candidal Sepsis SDX #2 I50.31 Acute diastolic heart failure
DRG Weight 1.9425	DRG Weight 1.8237

The weight difference of -0.1188 equates to ~$825. When hospitals are fighting for every dollar, these changes can add up! It can also negatively impact traditional CDI metrics like Case Mix Index and CC/MCC Capture rates.

Compliance reigns supreme

Coding guidelines stipulate that the complication must be sequenced first. We don’t get to ignore this simply because the outcome isn’t financially favorable.

The query must be sent. Compliance Is Still King.

The AHIMA Code of Ethics is explicit:

A health information management professional shall not: (not all-inclusive list)

4.8 Participate in, condone, or be associated with dishonesty, fraud, abuse, or deception.

Allowing patterns of optimizing or minimizing documentation/coding to impact payment

Miscoding to avoid conflict with others

Hiding or ignoring review outcomes

In other words:

Choosing not to query because it reduces reimbursement is manipulation.

Silence can be fraud.

Avoiding a query to prevent a downgrade is flat-out noncompliant.

Our obligation is to accuracy — not revenue.

Takeaway

If the clinical indicators support a diagnosis—but the documentation is unclear, inconsistent, or incomplete:

Send the query. Even if it lowers reimbursement.

The real risk is not the loss of $800. The real risk is ethical implications and payor denial.

Next on Query IQ

“Keep It Simple, Stupid.”

Why overly complex queries create unnecessary confusion, and how simplifying your queries can dramatically improve provider response accuracy, denials prevention, and CDI credibility.