If you’re tired of interruptions from Clinical Documentation staff, here’s a quick reference guide for major conditions that require full diagnoses.
Congestive Heart Failure: Need acuity and type.
Examples:
Acute on chronic diastolic CHF = NO QUERY
Chronic systolic CHF = NO QUERY
Acute CHF exacerbation = QUERY FOR CLARIFICATION
Respiratory Failure: Need acuity and type.
Examples:
Acute hypoxic respiratory failure = NO QUERY
Chronic hypercapneic respiratory failure = NO QUERY
Respiratory failure on home oxygen = QUERY FOR CLARIFICATION
CVA: Need laterality, vessel, and cause.
Example:
Left MCA CVA, likely embolic = NO QUERY
Right PCA CVA, likely thrombotic = NO QUERY
Acute ischemic stroke = QUERY FOR CLARIFICATION
UTI When There is a Foley Present: Is the infection due to the Foley?
Examples:
E Coli UTI due to Foley = NO QUERY
E Coli CAUTI = NO QUERY
E Coli UTI related to Foley = NO QUERY
E Coli UTI unrelated to Foley = NO QUERY
E Coli UTI in the setting of Foley = QUERY FOR CLARIFICATION
Fun Factoid: “in the setting of” is not linking language in ICD-10 and will require a query to clarify the relationship.
Sepsis in Presence of Device Infection: Is the sepsis due to the device infection?
Example:
Sepsis due to hemodialysis catheter infection = NO QUERY
Sepsis in the setting of hemodialysis catheter infection = QUERY FOR CLARIFICATION
Pressure Ulcers: Need type of ulcer, location, and POA status.
Example:
Stage 2 pressure injury to coccyx, POa = NO QUERY
Coccyx ulcer = QUERY FOR CLARIFICATION
STEMI: Need to specify location.
Example:
Anterior STEMI. = NO QUERY
STEMI = QUERY FOR CLARIFICATION
Malnutrition: Need to specify severity.
Examples:
Mild malnutrition = NO QUERY
Moderate malnutrition = NO QUERY
Severe malnutrition = NO QUERY
Malnourished = QUERY FOR CLARIFICATION
CKD: Need to specify stage.
Example:
Stage 3 CKD = NO QUERY
CKD = QUERY FOR CLARIFICATION
Encephalopathy: Need to specify type and cause.
Examples:
Metabolic encephalopathy due to pneumonia = NO QUERY
Toxic encephalopathy due to (specify drug or toxin) = NO QUERY
Other types of encephalopathy include hepatic, alcoholic, septic, hypertensive, anoxic/hypoxic encephalopathy.
Encephalopathy due to UTI = QUERY FOR CLARIFICATION
Post-Operative Complication: was it a complication of surgery, an expected post-op outcome, or due to underlying disease?
Examples: consider this clarification on diagnoses such as respiratory failure, shock, ileus, cardiac arrest, PE, or MI if they occur during or after surgery.