Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?

A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur

without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported.

Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?
A . Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add ‘morbid obesity with BMI 42 kg/m2’ to your next progress note.
B . Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add ‘morbid obesity with BMI 42 kg/m2’ to your next progress note.
C . Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient’s morbid obesity was present on admission and add the diagnosis to future progress notes?
D . Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)

View Answer

Answer: D

Explanation:

This is the most compliant query based on the most recent AHIMA/ACDIS query practice brief because it is non-leading, non-suggestive, and provides multiple options for the physician to choose from. It also does not imply any financial or quality implications for adding a diagnosis associated with the BMI.

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