CHICAGO – December 14, 2022 – The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Integrity Specialists (ACDIS) released today an updated practice brief, Guidelines for Achieving a Compliant Query Practice (2022 Update). The practice brief represents a joint effort between AHIMA and ACDIS to provide ongoing guidance regarding compliant querying.  

Clinical documentation integrity (CDI) and coding professionals rely on a query process to clarify documentation and code assignments for every encounter in a healthcare setting. The updated practice brief serves as a gold standard resource for professionals in all healthcare settings who participate in query processes and supports necessary industry-wide best practices for clinical documentation querying.  

“This updated practice brief is based on the CDI industry’s needs to support compliant query processes to ensure clinical documentation is patient-centered and of the highest level of integrity,” said Tammy Combs, RN, MSN, CCS, CCDS, CDIP, CNE, AHIMA practice director of CDI and clinical foundations and one of the brief’s co-authors. 

Healthcare organizations should integrate these best practices into business and workflow processes and the overall function of querying. 

Key updates in the practice brief include the following: 

• Query guidelines 
• The use of “unable to determine” in multiple-choice queries 
• The compliant use of CDI query templates 
• Information included on problem lists  
• The role of information from previous encounters 

“To develop this brief, we sought broad industry feedback in hopes of developing clear guidance and best practices related to provider queries,” said Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, interim director of ACDIS and director of CDI education at HCPRo. “Judging by the responses we received, the industry is very much committed to a compliant provider query process, which is exciting.”  

As healthcare delivery continues to evolve, AHIMA and ACDIS expect that future practice brief revisions will be required. 

Editor’s note: Reporters can complete this short form to read the updated practice brief or email ahimamedia@ahima.org for a copy.   

About AHIMA 

AHIMA is a global nonprofit association of health information (HI) professionals with more than 71,000 members and more than 100,000 credentials in the field. The AHIMA mission of empowering people to impact health^® drives our members and credentialed HI professionals to ensure that health information is accurate, complete, and available to patients and providers. Our leaders work at the intersection of healthcare, technology, and business and are found in data integrity and information privacy job functions worldwide.