Which subsequent documentation in the health record suggests the provider did not understand the query?

A patient’s progress note states "The patient has chronic systolic heart failure". After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure,

the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis.

Which subsequent documentation in the health record suggests the provider did not understand the query?

A. The patient has chronic systolic heart failure.

B. The patient has acute on chronic systolic heart failure.

C. The patient did have an exacerbation of heart failure.

D. The patient has decompensated systolic heart failure.

View Answer

Answer: A

Explanation:

According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement2. In this case, the CDIP queried the physician to clarify the current acuity of the diagnosis of chronic systolic heart failure, based on clinical indicators suggestive of an exacerbation of systolic heart failure. The subsequent documentation in the health record that suggests the provider did not understand the query is A. The patient has chronic systolic heart failure. This documentation does not address the query or provide any additional information about the patient’s condition. It simply repeats the same diagnosis that was already documented in the progress note. This documentation does not reflect the patient’s true severity of illness, risk of mortality, or reimbursement3. The other options are not correct because they do provide some information about the current acuity of the diagnosis of chronic systolic heart failure, such as acute on chronic, exacerbation, or decompensation. These terms indicate a higher level of severity and complexity than chronic alone.

References:

CDIP Exam Preparation Guide – AHIMA

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

Severity of Illness: What Is It? Why Is It Important? | HCPro

[Q&A: Acute on chronic versus decompensated heart failure | ACDIS]