By Robin Sewell, CCS, CDIP, CPC, CIC, CCDS-O
If your blood pressure spikes every time you read “denied due to query noncompliance,” you’re not alone and certainly not overreacting. Over the last few months, we’ve seen an uptick in query-related denials.
Sure, in some instances, queries could be of better quality (we’ve all seen that second query sent when the first response wasn’t what someone had hoped for), but let’s be honest: Most of these denials target compliant, well-documented, and clinically sound queries.
So, what’s going on?
A recent inclusion in their arsenal is the Guidelines for Achieving a Compliant Query Practice from the American Health Information Management (AHIMA)/Association of Clinical Documentation Integrity Specialists (ACDIS) where some payors are twisting the contents beyond recognition, as if it were written in a yoga manual instead of a legitimate medical record.
Let’s be clear: this is not a denial based on provider documentation per se.
It’s not a clinical concern for the patient.
It’s a revenue protection strategy by the payor.
Misusing the Query Brief to deny legitimate, clinical diagnoses identified through the query process is not only deceptive but may also be detrimental to hospital reimbursement.
Introducing Query IQ: Your Defense Against Denials
Welcome to Query IQ, an educational series designed to provide you with the tools, real-world query examples, and strategic best practices to defend compliant queries against denial games.
Payors should not rewrite the rules whenever a Major Complication or Comorbidity (MCC) tantalizes them.
Denial Debrief: The “Other” Excuse
Let’s walk through a recent denial example that’s almost too absurd to believe.
The Clinical Scenario
Operation Date: xx-xx-2025
Pre-op Diagnosis: Incarcerated epigastric hernia
Post-op Diagnosis: Strangulated epigastric hernia containing small bowel
Procedures:
- Diagnostic laparoscopy
- Open hernia repair
- Small bowel resection
Pathology Report Highlights:
- Small intestine: Segmental resection with ischemic enteritis
- Hernia sac: Confirmed incarceration
The Query Sent to the Provider
Based on the above, please provide an appropriate diagnosis that supports the clinical indicators, including evaluation, monitoring, and/or treatment:
- Acute ischemic bowel
- Chronic ischemic bowel
- Acute on chronic ischemic bowel
Physician Response: Acute ischemic bowel
Payor Denial: “No option for ‘Other’ was provided.”
Brundage Group Response: Including an “Other” or similar terminology is best practice, but let’s not kid ourselves: This was a clinically specific, well-structured query. The physician was asked to clarify the acuity of the ischemic bowel: Acute or Chronic, thus averting a default or unspecified code.
And guess what?
That’s precisely what the 2022 AHIMA Query Brief supports:
II. When to Query:
“To establish clinically supported acuity or specificity of a documented diagnosis to avoid reporting a default or unspecified code.”
That’s what we did. We avoided the non-specific K55.9 (Unspecified ischemic bowel) in favor of an accurate, more clinically meaningful code.
The Official Coding Guidelines Also Say…
- Use unspecified codes only when more specific documentation isn’t available
- Code to the highest level of specificity — if the info is there, use it
Query IQ Tip: Build Bulletproof Queries
Even when it feels redundant or out of place, always include “Other” or similar terminology in multiple-choice queries. This will not change the clinical truth but will remove a weak excuse for denial.
Think of “Other” as a seatbelt: You can leave it off, but we don’t recommend it, and it is the law!
Coming Up Next in Query IQ
Stay tuned for the next edition, where we’ll tackle the denial that claims: “You didn’t cite clinical indicators correctly.” (Spoiler: we did).
Need Support with Query Strategy or Denial Defense?
We’re here to help. At Brundage Group, our Physician Advisors are dedicated to defending hospitals against payors, assisting hospitals in capturing revenue for the quality care delivered, and improving documentation quality, all while easing the burden on bedside providers.
