DOCUMENTATION CLARIFICATION QUERIES
These sample physician query documents are offered solely as examples of standardized physician queries to clarify clinical documentation within the medical record. These query documents were created based on our interpretation of AHIMA/ACDIS guidelines and may be used by healthcare facilities at their own discretion.
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Recommendations for use: These query templates are designed for use as Word documents or e-messages and the content is to be edited and customized for the specific findings in each case. Suggested indicators not present in a particular case and/or multiple choice response options not supported by indicators (e.g., acute heart failure with only chronic indicators) should be deleted prior to submission to the provider. Content within brackets should be completed or deleted. Titles of each template are for reference only and should not appear on queries submitted to providers.
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DOCUMENTATION CLARIFICATION QUERIESTable of Contents
Topic Page No.Acute Coronary Syndrome 3Acute Kidney Injury (AKI) 4Acute Tubular Necrosis 5Anemia, Acute Blood Loss 6BMI > 40 7BMI < 19 8Chest Pain 9CHF – specify type only 10CHF – specify type and acuity 11CKD Stage 12Debridement, Excisional 13Depression 14Diabetic Gastroparesis 15Diabetic Complications 16Encephalopathy 17Encephalopathy causing Delirium 18Functional Quadriplegia 19GI Bleeding 20HIV/AIDS 21Hypertension (Crisis / Emergency) 22Malnutrition, severity 23Malnutrition, not yet diagnosed 24Pathologic / Osteoporotic Fracture 25Pancytopenia 26Pneumonia, Healthcare Associated (HCAP) 27-28Pneumonia, Aspiration 29Pressure Ulcer 30Respiratory Failure, Acute 31Respiratory Failure, Chronic 32Schizophrenia 33Sepsis 34Syncope 35TIA 36Urosepsis 37Probable/suspected cause of symptoms 38Specific diagnostic condition 39Clarification of a conflicting diagnosis 40Confirmation of a diagnosis 41Clinical validation query 42General query template 43
2
[Acute Coronary Syndrome]
Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having ACUTE CORONARY SYNDROME.
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following this condition is intended to indicate:
Transmural MI Subendocardial MI STEMI NSTEMI Unstable angina Other diagnosis (please specify) Not applicable / none of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
[Acute Kidney Injury]
Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having______________________________________________________.
3
The following lab is also documented in the medical record:
Creatinine on admission = _______ Baseline creatinine [if known]: _______
Correction of creatinine from ________ to ________ following rehydration
Creatinine increasing from _______ to _________ between ______ and _____ [dates]
Urine output ______ cc over ____ hours [if >6 hours and meets cc/kg/hr criteria]
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following these findings suggest:
Acute kidney injury (AKI) / acute renal failure
Acute on chronic renal failure
Chronic kidney disease / chronic renal failure (Please specify Stage)
Other condition
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
4
[Acute Tubular Necrosis (ATN)]
Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having Acute Kidney Injury (AKI).
Include the following clinical findings, as applicable, which support the query for ATN:
Prolonged elevation of creatinine (> 72 hours)
Oliguria (low urine output specified in cc/hr over what time period)
Hypotension (include specific blood pressure readings)
IV contrast administration
Nephrotoxic medication
The following is also documented in the medical record: Serial creatinine levels [and dates]: FENa = Urinary sodium concentration: Urinalysis [if applicable]: Other circumstances:
Based on your medical judgment, can you further clarify in the progress notes the likely cause of the acute renal failure or insufficiency in this case such as:
Acute Tubular Necrosis
Acute Cortical Necrosis
Acute Glomerulonephritis
Pre-Renal Acute Kidney Injury/Renal Failure
Another condition (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
[Acute Blood Loss Anemia]
5
Documentation in the medical record indicates the following:
Anemia
Drop in Hgb from ___ to ___
GI bleeding
Hypotension
Blood transfusion of __ units
Other
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following conditions are responsible for these findings:
Acute blood loss anemia Chronic blood loss anemia Acute on chronic blood loss anemia Acute hemorrhagic anemia Iron deficiency anemia Other anemia (please specify) Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
6
[BMI >40]
Documentation in the medical record indicates that this patient has:
BMI =
Other documentation includes:
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following conditions are associated with this BMI:
Overweight Obesity Morbid obesity Other condition (please specify) Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
7
[BMI < 19]
Documentation in the medical record indicates that this patient has:
BMI =
Other documentation includes:
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following conditions are associated with this BMI:
Underweight Malnutrition – if so please document severity Undernutrition Anorexia Other condition (please specify) Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
8
[Chest Pain]
Based on the documentation in the medical record, this patient was admitted with
CHEST PAIN.
Other information in the medical records includes:
Based on your medical judgment, is the chest pain most likely, possibly, probably due to any of the following causes:
Coronary artery disease Pleurisy Biliary colic GERD/reflux Costochondritis Anxiety Dyspepsia Gastritis Hyperventilation syndrome Cholelithiasis Cholecystitis Chest wall pain Esophagitis or spasm Hiatal hernia Peptic ulcer Other diagnosis (please specify)
□ Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
9
[CHF – specify type only]
Documentation in the medical record indicates that this patient is being treated for
HEART FAILURE / CHF.
Echocardiogram reports EF of __________ An EF of _____ is documented [location / by whom]
The patient has a history of [ESRD / Hypertension / Coronary artery disease]
Medications include:
Chest x-ray shows:
BNP =
Other documentation and findings include:
Based on your medical judgment, can you further clarify in the progress notes the precise nature of the patient’s heart failure/dysfunction for this admission such as:
SYSTOLIC
DIASTOLIC
COMBINED SYSTOLIC/DIASTOLIC
Other (please specify)
Not Applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
10
[CHF – Specify type and acuity]
Documentation in the medical record indicates that this patient is being treated for
HEART FAILURE or CHF.
Echocardiogram reports EF of __________
An EF of _____ is documented [location / by whom] The patient has a history of [ESRD / Hypertension / Coronary artery disease]
Medications include: ___________________________________________________
Chest x-ray shows: _____________________________________________________
BNP = ________
Other documentation and findings include:
Based on your medical judgment, can you further clarify in the progress notes the precise nature and severity of the patient’s heart failure for this admission, such as:
Systolic
Diastolic
Combined
Exacerbation / Decompensation (Acute)
Acute on Chronic
Chronic
Other (please specify)
Not Applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
11
[CKD Stage]
Based on the clinical information documented in the medical record, this patient has been diagnosed with Chronic Kidney Disease, Failure or Insufficiency.
Lab reports show a stable GFR of ____ to ____ from _______ to ________.
Stage GFR
CKD Stage 1 > 90
CKD Stage 2 60 – 89
CKD Stage 3 30 – 59
CKD Stage 4 15 – 29
CKD Stage 5 < 15
ESRD Need for dialysis
Based on your medical judgment, can you further clarify the appropriate stage of CKD in the progress notes?
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
12
[Debridement, Excisional]
Based on the documentation in the medical record, this patient has undergoneWOUND CARE and/or WOUND DEBRIDEMENT.
Based on your medical judgment, can you further clarify the precise nature, depth, extent and/or methods of wound debridement utilized in this case, such as:
EXCISIONAL debridement (use of a scalpel/blade to cut away tissue) NON-EXCISIONAL debridement (chemical, scrubbing, trimming with scissors) Other debridement (please specify) Other / Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
13
[Depression]
Documentation in the medical record indicates that this patient has been admitted with or
diagnosed as having DEPRESSION.
The following is also documented in the medical record:
_________________________________________________________________________
Based on your medical judgment, can you further clarify in the progress notes the status of
this patient’s DEPRESSION:
Type
Major depression
Simple depression
Severity
Mild
Moderate
Severe
Remission status
In remission
Not in remission
Other (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The
fact that a question is asked does not imply that any particular answer is desired or expected.
14
[Diabetic Gastroparesis]
Documentation in the medical record indicates that this patient has been diagnosed withDIABETES and is being treated for [GASTROINTESTINAL disorder].
Additional findings also documented in the medical record include [include all that apply]:
Vomiting without diarrhea
Distended stomach
History of similar or repeated episodes
History of peripheral or autonomic neuropathy
Abdominal pressure or swelling
Treatment with Reglan (metoclopromide)
Other (please specify
Not applicable / None of the above
Based on your medical judgment, can you further clarify in the progress notes a specific diagnosis, if any, related to these gastrointestinal symptoms/findings and the patient’s diabetes?
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
15
[Diabetic Complications]
Documentation in the medical record indicates that this patient has been diagnosed with
DIABETES and [the related complicating condition]
Additional findings include:
Based on your medical judgment, can you further clarify in the progress notes
whether or not the [related complicating condition] is due to diabetes? Other (please
specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
16
[Encephalopathy]
Documentation in the medical record indicates that this patient has been diagnosed as having the symptom of ALTERED MENTAL STATUS. Additional findings also documented in the medical record include: [include all the apply]
Fever Infection Dehydration / electrolyte imbalance Sepsis / SIRS Hypoxia Hepatic / renbal failure Abnormal lab tests: Drug toxicity or adverse effect:
Based on your medical judgment, can you further clarify in the progress notes any underlying neurologic cause, condition or process, if any, represented by this symptom including:
Metabolic Encephalopathy
Toxic Encephalopathy
Toxic-Metabolic Encephalopathy
Coma
Other condition (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
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[Encephalopathy causing Delirium]
Documentation in the medical record indicates that this patient has been diagnosed as having the symptom of DELIRIUM. Additional findings also documented in the medical record include: [include all that apply]
Fever Infection Dehydration / Electrolyte imbalance Sepsis/SIRS Hypoxia Hepatic/Renal Failure Abnormal lab tests: Drug toxicity or adverse effect:
Based on your medical judgment, can you further clarify in the progress notes the underlying cause, if any, of delirium including:
Metabolic encephalopathy
Toxic encephalopathy (drugs / toxins)
Toxic-Metabolic encephalopathy
A mental illness / disorder (please specify)
Circumstantial stress and/or sleep deprivation
Other (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
18
[Functional Quadriplegia]
Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having: [include all that apply]
Severe dementia Total care Activity level: Bedfast Mobility level: Completely immobile, or very limited Feeding tube Extreme / severe neurologic deficits Urinary / bowel incontinence Flexion contractures Other severe disability condition:
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following do the above conditions indicate (more than one if appropriate):
Functional Quadriplegia
Quadriparesis
Coma
Severe debility only
Paralysis
Other (please specify)
Not applicable / None of the above/
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
19
[GI Bleeding]
Documentation in the medical record indicates that this patient has been identified to have and/or is being treated for GI BLEEDING.
EGD / Colonoscopy findings: __________________________________________________
___________________________________________________________________________
Other information in the medical record includes: __________________________________
Based on your medical judgment, can you further clarify in the progress notes whether or not the GI bleeding is due to the [lesion(s) identified] ?
Other cause of GI bleeding (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
20
[HIV/AIDS]
Documentation in the medical record indicates the patient has:
HIV [or HIV “infection”] and
Current and/or prior CD4+ T-lymphocyte count of ________ and/or a history of the following conditions:
Based on your medical judgment, can you further clarify the HIV status of this patient:
HIV positive only / HIV infection (without AIDS)
HIV disease (AIDS)
Other condition (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
21
[Hypertensive Crisis / Emergency]
Documentation in the medical record indicates that this patient is being treated for
Hypertension
The following is also documented in the medical record :
Systolic BP consistently in the range of ___ to ___ from [dates]
Diastolic BP consistently in the range of ___ to ___ from [dates]
Other clinical findings [list any symptoms, diagnoses or evidence of organ dysfunction that might be due to hypertension]:
IV or STAT anti-hypertensive medications [includes oral Clonidine]: _____________________________________________________________________
Based on your medical judgment, can you further clarify in the progress notes whether the severity of hypertension in this case represents any of the following:
Hypertensive Crisis Hypertensive Emergency Hypertensive Urgency only Benign Hypertension only Hypertension without further specification Another condition (please specify) Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
22
[Malnutrition - severity]
The medical record indicates that this patient has been diagnosed as having MALNUTRITION with the following findings documented:
Clinical Findings [include all those that apply]:
o BMI < 16 (include actual BMI)
o Weight < 70% of ideal body weight (IBW)
o Weight < 75% of usual body weight (UBW)
o Unintended weight loss of > 5% in one month, > 7.5% in 3 months, > 10% in 6 months, or > 20% in one year: “Recent weight loss of _______ pounds over _______ months”
o Decreased hand grip strength
o Albumin and/or Prealbumin (if significantly low and not explained by other circumstances)
o Muscle wasting/atrophy
o Cachexia
High risk circumstances: [Cancer, malabsorption, other severe chronic GI disorder, debilitated, not eating, lack of social support, nursing home, other severe end-stage disease specified, alcohol/drug abuse]
Nutrition Consult:
Nutritional Supplementation:
Based on your medical judgment, can you further clarify in the progress notes the
SEVERITY OF MALNUTRITION:
Mild
Moderate
Severe
Other (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The
fact that a question is asked does not imply that any particular answer is desired or expected.
23
[Malnutrition – not yet diagnosed]
The following information is documented in the medical record regarding this patient’s nutritional status: Clinical Findings:
Nutrition Consult:
Nutritional Supplementation:
Based on your medical judgment, can you further clarify in the progress notes which, if any,
of the following conditions (and the severity, if applicable) may be causing these findings:
Malnutrition Weight loss only Underweight only Nutritional deficiency (please specify) Another cause (please specify) Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The
fact that a question is asked does not imply that any particular answer is desired or expected.
24
[Pathologic / Osteoporotic Compression Fracture]
[THIS QUERY NOT NEEDED FOR OSTEOPOROSIS IF IT IS DOCUMENTED ANYWHERE IN THE MEDICAL RECORD AND ONLY MINOR TRAUMA]
Dear Dr. ______________________________________________
Documentation in the medical record indicates that this patient has been diagnosed with VERTEBRAL COMPRESSION FRACTURE(S) [spontaneously or following minor trauma]
Other documentation in the medical record includes: [describe underlying cause like
neoplasm and any mets] [multiple other compression fractures, if any]
Imaging: [describe X-ray, CT, and/or MRI]
Medications: [for osteoporosis or neoplasm]
Osteopenia on _________ X-ray
Based on your medical judgment, can you further clarify in the progress notes the most likely underlying cause of the Compression Fracture(s)?
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
25
[Pancytopenia]
Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having [all that apply]:
Anemia
Neutropenia or Leukopenia
Thrombocytopenia
The following is also documented in the medical record:
Hemoglobin = ____ Gm/dl
Absolute Neutrophil Count (ANC) = ______
Platelets = _________
Other information [any pertinent]:
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following these findings suggest:
Pancytopenia, unspecified cause
Pancytopenia due to chemotherapy
Pancytopenia due to radiotherapy
Pancytopenia due to another drug
Another condition (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
26
INSTRUCTIONS – COMPLEX PNEUMONIA QUERY
On the following query, include the following clinical findings and risk factors, as applicable, which support the query for a more complex type of pneumonia, such as staph, gram-negative, aspiration or other complex pneumonia. If the patient has specific clinical indicators for aspiration, it may be more effective to use the Aspiration Pneumonia query.
HCAP: The predominant organisms causing HCAP (>80%) are gram-negative and staph . Antibiotics given ought to be those active against these organisms (see the CDI Pocket Guide).
Note: Patients who are receiving only antibiotics such as Rocephin, Zithromax, Quinolones (Levaquin or Avelox), or Doxycycline are usually being treated for a simple pneumonia, and this query may not be appropriate. Levaquin and Avalox are sometimes used for aspiration pneumonia. Cipro is sometimes used for Pseudomonas. Sometimes the physician may not have recognized aspiration as the cause and is not using an antibiotic for aspiration.
Clinical Findings: RLL infiltrate (aspiration) Open wound or ulcer (staph) IV catheter (staph) Structural lung disease like bronchiectasis (usually Pseudomonas) Recent antibiotic treatment Recent hospitalization
Risk Factors: Immuno-suppressed state Alcoholism / Drug abuse Ventilator status ESRD (often staph) Chronic debilitation GERD/esophageal disorder (aspiration) G-tube (aspiration) COPD (usually gram negative) Cancer Chemotherapy Steroids
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[Pneumonia, Healthcare Associated (HCAP)]
Based on the documentation in the medical record, this patient has been diagnosed withHCAP (Healthcare Associated Pneumonia) but without definitive culture confirmation.
Additional documentation in the medical record suggests a likely or probable organism(s)
causing pneumonia:
Antibiotics:
Other clinical information: _[include any clinical indicators suggesting or associated with
gram-negative and/or staph]
Based on your medical judgment, can you further clarify in the progress notes whether
HCAP in this case (for which these antibiotics are being given in these circumstances) is
suspected, most likely, possibly, probably related to one or more of the following:
Aspiration
MRSA
Other Staph
Gram negative
Pseudomonas
H. influenza
Pneumococcus
Another organism (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
28
[Aspiration Pneumonia]
Based on the documentation in the medical record, this patient has been diagnosed with
PNEUMONIA.
The following information is also documented in the medical record which may indicate a more specific type or cause of pneumonia:
______________________________________________________________________
[Include the following as applicable, which support the query for aspiration pneumonia:
Clinical Findings: RLL Infiltrate, vomiting, difficulty swallowing, impaired gag reflex, altered level of consciousness, abnormal swallowing study (normal study does not rule-out aspiration).
Risk Factors: Nursing home status, history of stroke / neurodegenerative disorder (e.g. MS, ALS), debilitated state / bed-confined, altered level of consciousness, alcoholic / drug intoxication or abuse, NG-tube, esophageal disorder (e.g. cancer, obstruction, stricture, etc.) / GERD.
Antibiotic treatment: Clindamycin, Flagyl, Zosyn, Augmentin, Levaquin, Avelox]
Based on your medical judgment, can you further clarify in the progress notes the likely or suspected underlying cause, if any, of the pneumonia in this case?
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
29
1
[Pressure Ulcer]
Documentation in the medical record indicates that this patient has been identified to have and/or is being treated for PRESSURE ULCER(s) of the following sites:
Please clarify the location/sites and the present on admission status of the ulcer(s) in the progress notes.
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
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[Respiratory Failure, Acute]
Documentation in the medical record indicates that this patient has been admitted with or
diagnosed as having______________________________________________________.
The following is also documented in the medical record: Respiratory symptoms: _________________________________________________
Respiratory Rate: ____________
pO2 = _____ [and/or SpO2 = ____] on room air
pCO2 = _____ with pH = _____
P/F Ratio = ________ [if reported on ABG]
Treatment: [O2 % or L/min; BiPAP; CPAP; Ventilator; bronchodilator]
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following this condition is intended to indicate:
Acute hypoxic respiratory failure
Acute hypercapnic respiratory failure
Acute on chronic respiratory failure
Chronic respiratory failure
Hypoxemia only without respiratory failure
Other
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
31
[Respiratory Failure, Chronic]
Documentation in the medical record indicates that this patient has been admitted with or
diagnosed as having ______________________________________________________.
The following is also documented in the medical record [mark all that apply]:
End-stage lung disease Severe COPD
Home oxygen therapy at ____L/min
Elevated pCO2 = __________ Elevated HCO3 = __________
Pulse ox (SpO2) = on ________ [O2 % or L/min on room air]
pO2 on ________ [O2 % or L/min on room air]
Other:_________________________________________________________
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following condition(s) is responsible for these findings:
Chronic respiratory failure Abnormal blood gases only Another condition (please specify) Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
32
[Schizophrenia]
Documentation in the medical record indicates that this patient has been admitted with or
diagnosed as having SCHIZOPHRENIA.
The following is also documented in the medical record:
Based on your medical judgment, can you further clarify in the progress notes the nature of
this patient’s schizophrenia :
Acuity
Acute
Chronic
Remission status
In remission
Not in remission
Other (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The
fact that a question is asked does not imply that any particular answer is desired or expected.
33
[Sepsis]
Based on documentation in the medical record, this patient is being treated for:
_________________________________________________________________________
The following criteria are also documented in the medical record [include only those that apply]:
Temperature = WBC = Pulse = Respirations = Lactate = Hypotension: Hypoxemia; SpO2 = ____ % on _____ O2 Acute kidney injury Acute respiratory distress/failure Mental status change / encephalopathy
Based on your medical judgment, can you further clarify in the progress notes the cause, if any, of these systemic findings including:
Sepsis
Septicemia
A localized infection only (without sepsis/septicemia)
Non-infectious SIRS
Another condition (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
34
[Syncope]
Documentation in the medical record indicates that this patient was admitted for or with SYNCOPE. Other documentation in the medical record includes:
___________________________________________________________________________
Based on your medical judgment, can you further clarify in the progress notes the most likely, possible, probable underlying cause, if any, of this symptom such as:
Cardiac arrhythmia Structural/valvular heart disease
Cardiovascular medication Cerebrovascular occlusion (partial or complete)
Anemia / GI bleeding Seizure Disorder
AV block Autonomic neuropathy
Dehydration
Hypoglycemia
Vaso-vagal / vaso-depressor
Another condition (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
35
[TIA]
Documentation in the medical record indicates that this patient has been admittedwith or diagnosed as having TIA.
The following information is also documented in the medical record:
Duration of symptoms: __________________________________
Atrial fibrillation
Abnormal Heart Valve(s)
Recent MI
Carotid Doppler showing:
Echocardiogram showing:
MRI or MRA showing:
Treatment with ASA Aggrenox Persantin Plavix Coumadin
Other: ______________________________________________________________
Based on your medical judgment, can you further clarify in the progress notes the possible, probable, likely, suspected underlying cause, if any, of the TIA symptoms such as:
Stroke / CVA
Transient cerebral thrombosis (without CVA)
Transient cerebral embolism (without CVA)
Occlusion or stenosis of a precerebral/cerebral artery (partial or complete) – please specify suspected artery
Another cause (please specify)
Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
36
[Urosepsis]
Based on the documentation in the medical record, this patient is being treated for or diagnosed with UROSEPSIS. Urosepsis is no longer a codeable diagnosis and we need help with clarification of the intended meaning.
Based on your medical judgment, can you please further clarify in the progress notes whether this term is intended to indicate:
UTI ONLY
SEPSIS DUE TO UTI
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
37
[Probable/suspected cause of symptoms]
Documentation in the medical record indicates the following:
Based on your medical judgment, can you further clarify in the progress notes the most
LIKELY, PROBABLE OR SUSPECTED CAUSE OF THIS CONDITION
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
Please note that your response may include: Not applicable or none.
38
[Specific Diagnostic Condition]
Documentation in the medical record indicates the following:
Based on your medical judgment, can you further clarify in your progress notes a
SPECIFIC DIAGNOSTIC CONDITION associated with or causing the above findings or
symptoms?
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
Please note that your response may include: None or not applicable.
39
Clarification of Conflicting Diagnoses
We need your assistance resolving some conflicting information in the medical record.
Dr. ____________________ documented the following diagnosis in his/her note on [Date]:
Dr. ____________________ documented the following diagnosis in his/her note on [Date]
Other documentation in the medical record also indicates: [information that supports the
diagnosis and/or causes conflict]:
Based on your medical judgment, please clarify in the progress notes which, in your opinion,
is the correct diagnosis in this case.
Please note that your response may include: None of the above (please explain) or another
diagnosis (please specify).
In responding to this request, please exercise your independent professional judgment. The
fact that a question is asked does not imply that any particular answer is desired or expected.
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Confirmation of a Diagnosis
The following diagnosis is documented in the record only once:
Other supporting information documented in the medical record includes:
Based on your medical judgment, please clarify in the progress notes whether or not
this patient actually has this diagnosis or, if not, another diagnosis (please specify)?
Please note that your response may include: Neither the documented diagnosis nor another
one.
In responding to this request, please exercise your independent professional judgment. The
fact that a question is asked does not imply that any particular answer is desired or expected.
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Clinical Validation
Your assistance with confirmation of a documented diagnosis is requested because we cannot
identify adequate information in the medical record to support code assignment in this case.
Diagnosis: ______________________________________________________
Would you please clarify in the patient medical record whether:
1. This diagnosis is not confirmed and/or it has been ruled out.
2. This diagnosis is confirmed (please add additional supporting information to the
medical record)
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[General Query Template]
Documentation in the medical record indicates the following:
Based on your medical judgment, can you further clarify the following in the progress notes:
Responses may include: Other (please specify) / Not applicable / None of the above
In responding to this request, please exercise your independent professional judgment. The
fact that a question is asked does not imply that any particular answer is desired or expected.
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