When compliantly querying providers, CDI specialists or HIM/coding professionals may
A.
offer diagnoses choices supported by documentation solely from previous encounters.
B.
identify which diagnoses are HCCs.
C.
offer a new diagnosis, that is supported by the clinical evidence, as an option in a multiple-choice query.
D.
omit clinical indicators in a query as this may be leading to the provider.
The Answer Is:
C
This question includes an explanation.
Explanation:
Compliant querying principles taught in outpatient CDI allow the CDI/coding professional to present a multiple-choice query that includes reasonable diagnostic optionssupported by the current encounter’s clinical indicators. Including a “new” diagnosis as an option is acceptable when it is clinically supported by documented findings (signs/symptoms, test results, treatments, clinical course) and the query is written in a non-leading manner—typically with balanced options and an “other” and/or “unable to determine” choice. This approach helps the provider clarify the most accurate condition being evaluated or treated without steering toward a particular response. Option A is not compliant because relying solely on prior encounter documentation (without current relevance) risks coding historical conditions that are not addressed today. Option B is generally discouraged because calling out HCC status can be perceived as prompting for payment impact rather than clinical accuracy. Option D is incorrect because including relevant clinical indicators is essential; omitting them weakens the clinical basis and does not make a query less leading—rather, it makes it less defensible.
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