By Robin Sewell, CCS, CDIP, CPC, CIC, CCDS-O
When Payors Demand More Than What’s Required
A query walks into a hospital, and the payor says, “Sorry, we don’t serve your kind here without source documentation citations.”
It’s a joke — but lately, most query-related denials are.
We recently received a denial claiming that an otherwise compliant query was invalid because it didn’t specify the exact location of clinical indicators in the record. And just in case that argument didn’t hold up, the payor added a second layer — stating the condition couldn’t be reported because it wasn’t treated.
The payor stated:
“Upon review of the medical record and the available physician query form, there was no citation or location of clinical indicators, and it was not compliant per AHIMA query guideline practice. The query did not have treatment for non-ischemic myocardial injury.” This reflects a growing trend: Misapplying industry guidance to justify denials. For context, this is what The American Health Information Management Association – Association of Clinical Documentation Integrity Specialists (AHIMA-ACDIS) Practice Brief states regarding citation location of clinical indicators: “Clinical indicators should include a citation of the location found within the health record.”
Denial Debrief: Myocardial Injury Clarification
Here’s the query in question:
This query is being sent for clarification of the following documentation in the medical record:
- ED documentation: The patient presented for evaluation of loss of peripheral vision and headache. Admitted for CVA.
- Cardiology note: Denies chest pain, shortness of breath, dizziness, lightheadedness, syncope.
- Troponin trend: 21 → 40 → 182 → 401
- EKG: Sinus rhythm with nonspecific abnormalities
An ischemic workup was deferred in the acute CVA setting with no ischemic symptoms. Type 2 MI suspected.
Based on your medical judgment, please clarify which, if any, of the following diagnoses apply:
- (X) Non-ischemic Myocardial Injury
- ( ) Type 2 MI due to _______
- ( ) Other: __________________
The physician selected Non-ischemic Myocardial Injury in response.
The diagnosis was denied despite referencing the ED and cardiology documentation, the source of the clinical indicators, and outlining clear clinical indicators.
Response: Clarification Is the Purpose
This query is both appropriate and compliant. It was issued to clarify whether a suspected diagnosis—Type 2 MI—was ruled in, ruled out, or should be otherwise specified. That intent is fully supported by the 2022 AHIMA/ACDIS Practice Brief, which states that compliant queries may be used:
- To establish clinically supported acuity or specificity of a documented diagnosis to avoid reporting a default or unspecified code
- To determine if a diagnosis is ruled in or ruled out
The denial incorrectly claimed the absence of treatment invalidated the query. Official Coding Guidelines do not require treatment as a required element for capturing a secondary diagnosis and the Practice Brief does not require treatment as a clinical indicator. Valid clinical indicators may also include (among others):
- Evaluation
- Monitoring
- Diagnostics
- Clinical Context
In this case, the troponin trend combined with a lack of ischemic symptoms, and clear documentation of suspected Type 2 MI provided a defensible, clinically sound rationale for clarification.
Additionally, the query clearly sourced the “cardiology note” rendering the payor’s interpretation of the Query Brief invalid.
Final Thought
This denial reflects a broader issue: payors are shifting focus from the clinical appropriateness of a query to technical aspects of query formatting. Industry standards remain unchanged; keep your queries clear, specific, and rooted in the record to withstand scrutiny.
Next in Query IQ
Is Your Query Structure Friend or Foe? We’ll explore how templates can boost efficiency or unintentionally invite denials.
Need Support? We’re Here to Help.
If your team is seeing an increase in denials based on query structure or documentation ambiguity, you’re not alone and don’t have to navigate it alone.
Brundage Group offers expert Physician Advisor services, defensible query review, and denial management support to help protect earned revenue and ensure your documentation holds up under scrutiny.
