Even when they use technology, hospitals are responsible for ensuring their queries are compliant, according to a 2022 practice brief from the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Integrity Specialists (ACDIS) that was released Oct. 10.^[1] Compliant queries are an industry standard, and CMS has echoed the concerns about “leading” queries that point physicians to diagnoses that may generate higher reimbursement.

The purpose of a compliant query is to clarify information about diagnoses and procedures and help providers create thorough and complete documentation in the medical record.^[2] Coders and clinical documentation specialists (CDSs) typically submit queries to physicians to get a fix on the patient’s diagnosis for coding and documentation integrity purposes.

“Even if you’re doing a technology solution, it has to meet query requirements,” said Erica Remer, M.D., co-host of Talk Ten Tuesday, a weekly podcast. “If your artificial intelligence is saying these clinical indicators indicate this one specific condition, that is not compliant because it is leading. Technology is only as good as the people who designed it.” If she developed technology-driven queries, “In addition to offering all appropriate choices which matched the clinical indicators, I would have a disclaimer to say, ‘You always have the option of declining our suggested diagnosis,’ or always have a choice of ‘other.’”

The practice brief has significant additions and more explicit discussions of definitions. It addresses query templates, problem lists and who and when to query, among other things, said Melissa Potts, a CDI practitioner at AHIMA, at the Oct. 11 Talk Ten Tuesday. There’s a two-week comment period on the practice brief before it’s finalized, she said.