The role of clinical indicators in queries

Clinical indicators are a key component of query construction. To justify its issuance, a query must cite clinical indicators specific to the patient and the episode of care. Clinical indicators can support the request for documentation of a missing diagnosis or more specificity of a documented diagnosis. They also come into play during queries for clinical validation of a documented diagnosis that appears to lack adequate support.

Clinical indicators are found throughout the medical record. These indicators are the support needed to validate the presence of a diagnosis. They are the criteria that led the physician or licensed provider to assign the specific diagnosis. This information can be pulled from laboratory and diagnostic tests, cultures, screening tests, imaging studies, and so forth. Many conditions call for specific treatments, including medications, interventions, or monitoring, and the application of those treatments would support the presence of a particular condition. For example, if a patient has major depressive disorder, the physician will evaluate the patient’s symptoms and functional status and may refer the patient to psychiatric care and/or medication management.

The patient’s medical history can also provide clinical indicators. Does the patient’s history imply susceptibility to certain conditions? Has the patient been exposed to specific infectious organisms? How did the patient respond to previous plans of care? What treatments seemed to lead to improvement? What treatments failed? All of this information provides clues that the provider uses to identify a specific diagnosis.

Often, documentation from nurses, therapists, dietitians, etc. will provide support for specific diagnoses. Nursing observations of patient behaviors and responses to care are important. And, of course, the objective information within the record is important as well, including height, weight, and trending of vital signs and hemoglobin A1c values. All of this information can be used to support the presence of a specific diagnosis.

Documentation from previous encounters may be used as clinical indicators to formulate a query for instances such as:

• When diagnostic criteria support the presence and/or increased specificity of a currently documented diagnosis (e.g., type of heart failure, stage of CKD, presence of preexisting pressure ulcer)
• When a previous encounter included a treatment or diagnosis relevant to the current encounter
• Determination of the patient’s baseline function as compared to present function (e.g., an exacerbation of a chronic condition)
• To clarify a cause-and-effect relationship (e.g., a possible complication related to previous care/interventions)
• Determination of the etiology of documented signs or symptoms

A query should cite the location within the medical record of each clinical indicator it uses for support. Example: “AKI with acute tubular necrosis (nephrology consult note dated 02/06).”

Editor’s note: This article is an excerpt from the “2025 JustCoding Pocket Guide” by Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS.