CDI Assessment - Query Generation 2
Step 1: Assess the Scenario Carefully review the clinical documentation and determine whether there is a need to issue a provider query. A query is warranted when the documentation is ambiguous, incomplete, inconsistent, or lacks clinical specificity that could impact coding, severity, or quality reporting.
Step 2: Apply the Three-Legged Approach If a query is needed, construct it using the three-legged approach, which ensures compliance by including:
Clinical Indicators – Objective findings such as lab results, imaging, symptoms, or treatments.
Treatment/Risk/Monitoring – Evidence that the condition is being actively managed, poses risk, or requires monitoring.
Open-Ended or Multiple-Choice Question – A non-leading, clinically neutral question with appropriate response options.
Step 3: Ensure Compliance.
This quiz is timed.
The total time allowed for this quiz is 9 hours. |
This quiz requires you to log in.
Please enter your Quia username and password. |
|
|
|
