Query IQ: Clarify Without Leading

By Cheryl Ericson, RN, MS, CCDS, CDIP and Robin Sewell, CCS, CDIP, CPC, CIC, CCDS-O

In our last issue of Query IQ, we talked about approaching queries with a scientific mindset: Start with a hypothesis, build your case with solid clinical evidence, and structure your query accordingly. Sounds simple, right? Well… not exactly. 

Crafting a query that’s clear, compliant, and clinically meaningful is both an art and a science. I’ve got the science part down — hypothesizing and digging through data is second nature. But when it comes to the art of structuring a truly compliant, well-balanced query, I often turn to my colleague Cheryl Ericson, Director of UM and CDI at Brundage Group. 

In this edition of Query IQ, Cheryl and I discuss how to craft a clean, compliant, and non-leading query in a real-world scenario where I hesitated to recommend a query for fear it could appear leading. 

 The Scenario: When the Clues Are There, but the Diagnosis Isn’t 

A patient presented without chest pain but had a notable rise in troponin values, peaking at over 1000. Imaging showed anteroseptal hypokinesis on echo. The clinical picture appeared to meet criteria for a Type 2 NSTEMI, but instead the provider documented on the Discharge Summary: “Elevated troponin… suspected to be nonischemic myocardial injury related to sepsis… further cardiac workup deferred to outpatient.” 
 
From a coding perspective, this is a self-inflicted wound! The criteria for Type 2 NSTEMI were met, but the diagnosis was documented as something else; a completely different ICD-10 code! 

Clinical Criteria for Type 2 NSTEMI: 

According to the Fourth Universal Definition of Myocardial Infarction, Type 2 MI requires: 

Plus at least one of the following: 

In this case, the troponin trend and anteroseptal hypokinesis fulfill the criteria for Type 2 NSTEMI. But how do I pose that question when the provider has already documented non-ischemic myocardial injury-on the Discharge Summary? 

Putting on my payor hat for a moment, I can already hear the argument: “Why ask the question? The provider already documented something else.” Call it a little PTSD from all the query-related denials — but it’s exactly this kind of scenario that makes compliant query structure so important. 

Why a Query Is Appropriate in this Scenario 

In this scenario we could apply the inpatient coding guideline regarding uncertain diagnoses,  

If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. 

Or we could query the provider to see if he/she is comfortable making a definitive diagnosis. According to the Guidelines for Achieving a Compliant Query Practice (2022 Update), ambiguous documentation, defined as “documentation that fails to reflect the provider’s intent, impacts the clinical scenario (e.g., diagnoses, complications, quality of care issues), the accuracy of code assignment, and/or the ability to assign a code,” is a general query convention. In this case, we are not sure the current documentation accurately reflects the clinical scenario; therefore, querying is appropriate.  

A query is also supported by coding guidelines because the provider documented “elevated troponin” which is an abnormal finding. In this example, we know additional testing was ordered, an ECHO, which found anteroseptal hypokinesis. The Abnormal Finding guideline states, “If the findings are outside the normal range and the provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.” The discharge documentation does not appear to fully address this significant abnormal finding; therefore, a query is appropriate.  

Clinically, there is conflicting documentation in the health record. It is not uncommon for a diagnosis to be validated with additional investigation, but in this example, the documentation addressing the high troponin levels was uncertain. Additionally, providers documented the possibility of both “myocardial injury” and “nonischemic myocardial injury” injury. The code set assumes “myocardial injury” to be the same as “nonischemic myocardial injury” because “nonischemic” is an unnecessary modifier but clinically, we cannot assume the intent of the provider. The American Journal of Medicine (August 2022) states, “Diagnosis and therapy of type 1 MI are well understood and usually present no problem to the physician.  The clinical scenarios leading to type 2 MI and non-ischemic myocardial injury are, however, often fraught with greater degrees of uncertainty.” This report follows a 2019 article in JAMA Cardiology that found, “Patients with nonischemic myocardial injury frequently receive incorrect diagnoses and are billed as having T2MI.” It is appropriate to query when there is conflicting documentation in the health record. This is where having access to a physician advisor is helpful because they can assist with determining if the clinical scenario is accurately represented by the current documentation. Remember, we must not only rely on coding conventions and guidelines, but also continuity of the clinical scenario.  

The Query 

Because querying is somewhat subjective, query professionals and payors may disagree what is necessary for a query to be compliant with industry guidance. Payors may try to challenge a simple, concise query but being clear and concise is a general query guideline.  

Most providers prefer when the query begins with the question because not all providers need to review the included clinical indicators depending on their familiarity with the patient. It is also not necessary to ask the provider to use their independent judgment, the provider is legally responsible for establishing diagnoses. Just like health information professionals, medical professionals must abide by a code of ethics; however, providers must also be weary of liability so there is even more incentive for a provider to accurately diagnosis and treat a patient.  

Based on the clinical indicators presented below, can the conflicting documentation of in the health record be further clarified as   
( ) Type 2 NSTEMI  
( ) Non-ischemic myocardial injury  
( ) Other (please specify): _________________

Clinical Indicators from the Medical Record