Query IQ: When Clinical Indicators Don’t Match the Diagnosis 

When the clinical indicators listed in a query don’t support the response options, it becomes vulnerable to denial as a noncompliant or leading query. 

In this edition of Query IQ, we examine a real example in which sepsis was included as a query option without adequate clinical support, resulting in a denial for “introducing an undocumented diagnosis.” 

What the Guideline Says 

According to the 2022 AHIMA/ACDIS Query Brief: 

Compliant Query Guidelines (Page 6) 

II. Diagnosis answer options that are not already documented in the health record must be supported by clinical indicators sourced from the medical record. These clinical indicators must be included within the query.   

What the Guideline Means 

Payors often misinterpret this guideline to mean that an undocumented diagnosis may never be presented as a query option. However, that is not what the guideline means. The above guideline means that if the documentation has clinical indicators to support a query, the condition may be presented as a query option, even if the actual condition is not yet documented.   

 CDI work is a lot like detective work, with one key difference — you can search for clues, but you can’t plant them at the crime scene.  You can only ask about the diagnosis if the “clues” are already there — evidence such as abnormal diagnostics, or treatment without an associated diagnosis. If offering a diagnosis as a query answer option without enough clinical support, you’re not solving the case — you’re framing it.   

 Here’s an example we found… 

The Quirky Query  

Based on documentation in the medical record, this patient is being treated for right lower extremity cellulitis. This patient is status post liver transplant on immunosuppressive therapy. 

The following are also documented in the medical record: 

• Platelets = 88 on xx/xx/xx 

Based on your medical judgment, can you further clarify the cause of these findings such as: 

• Sepsis 

• A localized infection only (cellulitis, right lower extremity) 

• Another condition (please specify) 

What went wrong?  

You may have spotted it right away! Sepsis criteria were weak at best — and the patient had clear underlying liver disease, including post-liver transplantation. Thrombocytopenia in this setting is more likely related to baseline pathology. Listing sepsis as a response option introduced a new diagnosis without support, making the query noncompliant. 

The Payor Perspective 

Most payors rely on Sepsis-3 criteria, which include: 

• Infection 

• A SOFA score increase ≥2 (organ dysfunction directly attributable to infection) 

Many payors take it even further, applying interpretations not directly found in sepsis literature. For instance, they may require that organ dysfunction be “remote” from the site of infection. In other words, they will not apply SOFA criteria if organ dysfunction could otherwise be attributable to a chronic condition. For example, they will routinely discount: 

• P/F ratio abnormalities if sepsis is due to pneumonia 

• Elevated creatinine if the patient has CKD 

• Elevated bilirubin if the patient has chronic liver disease 

• And yes — thrombocytopenia in a post-transplant liver recipient 

Step Away from the Query 

 In this case, the query-based denial was legit. There was no compliant way to introduce sepsis as a diagnosis option. The clinical indicators — including the patient’s immunosuppressed state and platelet count of 88 — may have triggered a second look by the CDI, but without documentation linking the thrombocytopenia to infection, a query for sepsis would be speculative at best. In fact, this may be viewed as a fishing expedition! 

Final Takeaway 

To compliantly introduce a diagnosis in a query, the indicators must clearly support it. The organ dysfunction must be attributed AT LEAST IN PART to infection to pass scrutiny and to be compliant.