A query should be generated when documentation contains a

A query should be generated when documentation contains a
A . postoperative hospital-acquired condition
B . principal diagnosis without an MCC
C . diagnosis without clinical validation
D . problem list with symptoms related to the chief complaint

View Answer

Answer: C

Explanation:

A query should be generated when documentation contains a diagnosis without clinical validation, meaning that there is no evidence in the health record to support the diagnosis or that the diagnosis is inconsistent with other clinical indicators. A diagnosis without clinical validation may affect the accuracy and completeness of coding, quality measures, reimbursement, and patient care.

References: AHIMA/ACDIS. “Guidelines for Achieving a Compliant Query Practice (2019 Update).” Journal of AHIMA 90, no. 2 (February 2019): 20-29.