Q: Is a query titled “Sepsis Query” considered leading even if it is an open-ended question?
A: We must remember that we cannot be leading in our query practice; we cannot point out which answer we anticipate. We also do not want to indicate anywhere on the query form an expected payment or reimbursement based on the answer provided.
For example, you cannot refer to a relative weight based on multiple choice answers, or which answer is a CC/MCC. Labeling a query with a title can also be interpreted as leading. In your example “Sepsis Query” may indicate the answer you wish to receive is “sepsis.” I have seen queries for functional quadriplegia labeled as such and this is leading in nature. Another famous query that is often titled with the answer is “Acute Blood Loss Anemia.” So use caution in titles of queries.
Because of our software programs, we often categorize queries by subject so that when you are looking for the template for “acute respiratory failure” you can easily find it in your template dictionary. Although it is fine for it to be labeled in your system that way, the version seen by the provider should not be titled. You can understand how it would appear leading to query for a respiratory function clarification when a multiple choice answer is “acute respiratory failure” and the title of the query is the same. You may not intend to lead, but the provider will have a very good clue of exactly what answer you are “banking” on.
Editor’s note: Laurie Prescott, MSN, RN, CCDS, a CDI education specialist for HCPro, a division of BLR, in Danvers, Massachusetts, answered this 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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