Q: Is it appropriate to introduce new information in a multiple choice-formatted query?
A: AHIMA’s 2008 physician query practice brief—as well as subsequent revisions in this brief—do allow coders and clinical documentation improvement specialists to introduce new information when using a multiple choice-formatted query.
However, the caveat is that the new information cannot be included in the actual question itself, nor can it be included in the title of the query. New information can be included in one or more of the answer options when clinical elements in the health record support the inclusion of those options.
Guidelines for Achieving a Compliant Query Practice—the most recent version of the practice brief released in February 2013—states the following:
…Providing a new diagnosis as an option in a multiple choice list, as supported and substantiated by referenced clinical indicators from the health record, is not introducing new information.
In some cases, a new diagnosis may be the only option listed in the multiple choice format along with ‘other’ and ‘clinically undetermined.’
Editor’s note: William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc. in Fort Walton Beach, Fla. answered the previous question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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