ACDIS publishes outpatient query process position paper

January 15, 2018

With providers continuing to expand clinical documentation improvement (CDI) efforts into outpatient settings, ACDIS has published a position paper offering guidance to outpatient CDI departments for performing queries.

Queries in Outpatient CDI: Developing a Compliant, Effective Process”  was written by a committee of 10 industry experts and approved by external sources and the ACDIS Advisory Board.

In 2013, the HIM and CDI industry jointly published AHIMA/ACDIS Guidelines for Achieving an Effective Query Practice, which set the standard for query practice within the inpatient setting. These guidelines defined acceptable practices for concurrent record review in the inpatient setting and set the foundation for a position paper specific to physician queries in the outpatient setting.

Published January 8, the position paper for outpatient CDI provides detailed guidance to help CDI specialists clarify documentation within the health record. The paper covers the use of prior medical records to query a physician, and encourages CDI specialists to perform interventions to help physicians manage problem lists.

ACDIS has made “Queries in outpatient CDI: Developing a compliant, effective process” available to both ADCIS members and non-members, so all CDI professionals can access industry recommendations and best practices for physician queries.

ACDIS encourages feedback on the position paper and will be reviewing its content during their ACDIS Membership Quarterly Conference Call of February 16.