What can be done to improve this rate?

The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query.

What can be done to improve this rate?
A . Have CDI manager teaming with coding supervisor to monitor physician responses
B . Require physicians to document responses in charts
C . Permit CDI practitioners to document physician responses in the charts
D . Allow physician to respond via e-mail

View Answer

Answer: B

Explanation:

According to the AHIMA/ACDIS Query Practice Brief, one of the best practices for a compliant query process is to require physicians to document their responses to queries in the health record1. This ensures that the documentation is consistent, accurate, and complete, and that the query and response are part of the permanent record. Verbal responses are not acceptable, as they do not provide a clear audit trail and may lead to errors or discrepancies in coding and billing1. Therefore, the CDI manager should educate the physicians on the importance of documenting their responses in the charts and monitor their compliance. The other options are

not recommended, as they may compromise the integrity of the documentation or violate the query guidelines1.

References: Guidelines for Achieving a Compliant Query Practice (2019 Update) – AHIMA