CHICAGO – July 15, 2019 – The evolution of reimbursement methods, moving beyond resource use to a more descriptive account of the patient’s diagnosis and care given, is driving the need for more precise and accurate clinical documentation—and industry-wide best practices for clinical documentation querying.

At the American Health Information Management Association’s (AHIMA) CDI Summit, coauthors of the brief, Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, and William Haik, MD, FACCP, CDIP, shared insights from the AHIMA and Association of Clinical Documentation Improvement Specialists (ACDIS) updated practice brief, Guidelines for Achieving a Compliant Query Practice (2019 Update).

Clinical documentation improvement (CDI) and coding professionals rely on a query process to clarify documentation and code assignment for every encounter in a healthcare setting. The updated practice brief serves as a gold standard resource for professionals in all healthcare settings who participate in query processes and supports necessary industry-wide best practices for clinical documentation querying, according to the authors. The best practices should be integrated into the healthcare organizations’ business and workflow processes and the overall function of querying.

“Our goal for this brief is to provide an ethical standard across the board for everyone involved in performing queries to ensure each patient’s encounter with a healthcare professional is accurately reflected in their health record. Incorrect documentation can result in issues including billing errors and misrepresentation in a patient’s health history,” Bryant said.

Key updates in the practice brief include:

• When and how to use prior encounters in queries
• Defining the term “clinical indicators”
• Using query templates to write queries with non-leading language
• Reiterating that one should avoid using the word “possible” in all queries

“A patient’s health record paints a richer picture of their history,” Haik said. “As a physician, it’s important to use this brief to work alongside coding and CDI professionals to standardize the query process and ensure that every patient’s health history is accurately documented.”

“When technology shifts and advances, HIM professionals step up, adjusting and improving the way we do our job,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “This updated practice brief serves as a check and balance for everyone involved in the query process to ensure accuracy and compliance throughout.”

Also presented at the summit

The Importance of Accurate Documentation and Coding – A Physician’s Perspective

Dr. Rae Godsey, DO, MBA, CPC, Associate Vice-President/Medical Director, Risk Adjustment and STARS at Humana shared the physician’s perspective about the best practices for achieving accurate documentation and coding to capture the true heath status of the patient. Godsey will also dive into how important this is in the changing healthcare landscape.

The AHIMA CDI Summit is the premier industry event attended by key leaders and professionals in CDI and coding and is dedicated to advancing the documentation journey and exploring the challenges presented by today’s complex healthcare environment. The Summit is taking place July 14-15, 2019, in Chicago.

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About AHIMA
AHIMA is a global nonprofit association of health information (HI) professionals. AHIMA represents professionals who work with health data for more than one billion patient visits each year. AHIMA’s mission of empowering people to impact health drives our members and credentialed HI professionals to ensure that health information is accurate, complete, and available to patients and providers. Our leaders work at the intersection of healthcare, technology, and business, and are found in data integrity and information privacy job functions worldwide.