A query can be a powerful communication tool used to clarify documentation in the health record and achieve accurate code assignments. This Practice Brief In Addition provides examples of the different forms of queries available to HIM professionals.


Example Verbal Query Documentation

The documentation of verbal queries should follow a standard format to include all necessary information.

Spoke with Dr. X regarding the documentation of   (condition/procedure)   based upon the clinical indicator(s) found in the health record   (list what was found and where)  .


Example Open-Ended Query

A patient is admitted with pneumonia. The admitting H&P examination reveals WBC of 14,000; a respiratory rate of 24; a temperature of 102 degrees; heart rate of 120; hypotension; and altered mental status. The patient is administered an IV antibiotic and IV fluid resuscitation.

Leading: The patient has elevated WBCs, tachycardia, and is given an IV antibiotic for Pseudomonas cultured from the blood. Are you treating for sepsis?

Nonleading: Based on your clinical judgment, can you provide a diagnosis that represents the below-listed clinical indicators?

In this patient admitted with pneumonia, the admitting history and physical examination reveals the following:

  • WBC 14,000
  • Respiratory rate 24
  • Temperature 102° F
  • Heart rate 120
  • Hypotension
  • Altered mental status
  • IV antibiotic administration
  • IV fluid resuscitation

Please document the condition and the causative organism (if known) in the medical record.

Source: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): expanded web version.


Example Multiple Choice Query

A patient is admitted for a right hip fracture. The H&P notes that the patient has a history of chronic congestive heart failure. A recent echocardiogram showed left ventricular ejection fraction (EF) of 25 percent. The patient’s home medications include metoprolol XL, lisinopril, and Lasix.

Leading: Please document if you agree the patient has chronic diastolic heart failure.

Nonleading: It is noted in the impression of the H&P that the patient has chronic congestive heart failure and a recent echocardiogram noted under the cardiac review of systems reveals an EF of 25 percent. Can the chronic heart failure be further specified as:

  • Chronic systolic heart failure____________________
  • Chronic diastolic heart failure___________________
  • Chronic systolic and diastolic heart failure_________
  • Some other type of heart failure _________________
  • Undetermined________________________________

Source: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): expanded web version.


Example Yes/No Queries
Compliant Example 1

Clinical Scenario: A patient is admitted with cellulitis around a recent operative wound site, and only cellulitis is documented without any relationship to the recent surgical procedure.

Query: Is the cellulitis due to or the result of the surgical procedure? Please document your response in the health record or below.

Yes _____________

No ______________

Other ___________

Clinically Undetermined ______________

Name: ___________________          Date:__________

Rationale: This is an example of a yes/no query involving a documented condition potentially resulting from a procedure.

Compliant Example 2

Clinical scenario: Congestive heart failure is documented in the final discharge statement in a patient who is noted to have an echocardiographic interpretation of systolic dysfunction and is maintained on lisinopril, Lasix, and Lanoxin.

Query: Based on the echocardiographic interpretation of systolic dysfunction in this patient maintained on lisinopril, Lasix, and Lanoxin can your documentation of “congestive heart failure” be further specified as systolic congestive heart failure? Please document your response in the health record or below.

Yes _____________

No ______________

Other ___________

Clinically Undetermined____________

Name: ___________________          Date:__________

Rationale: This yes/no query provides an example of determining the specificity of a condition that is documented as an interpretation of an echocardiogram.

Compliant Example 3

Clinical scenario: During the removal of an abdominal mass, the surgeon documents, in the description of the operative procedure, a “serosal injury to the stomach was repaired with interrupted sutures.”

Query: In the description of the operative procedure a serosal injury to the stomach was noted and repaired with interrupted sutures. Was this serosal injury and repair:

A complication of the procedure _____________

Integral to the above procedure _____________

Not clinically significant ____________________

Other ___________

Clinically Undetermined____________

Please document your response in the health record or below accompanied by clinical substantiation.

Name: ___________________          Date:__________

Rationale: This is an example of a query necessary to determine the clinical significance of a condition resulting from a procedure.

Non-Compliant Example 1

Clinical scenario: On admission bilateral lower extremity edema is noted, however, there are no other clinical indicators to support malnutrition.

Query: Do you agree that the patient’s bilateral lower extremity edema is diagnostic of malnutrition? Please document your response in the health record or below.


No ______________

Other ___________

Clinically Undetermined ______________

Name: ___________________          Date:__________

Rationale: Malnutrition is not a further specification of the isolated finding of a bilateral lower extremity edema. An open-ended or multiple choice query should be used under this circumstance to ascertain the underlying cause of the patient’s edema.

Non-Compliant Example 2

Clinical scenario: A patient is admitted with an acute gastrointestinal bleed, and the hemoglobin drops from 12 g/dL to 7.5 g/dL and two units of packed red blood cells are transfused. The physician documents anemia in the final discharge statement.

Query: In this patient admitted with a gastrointestinal bleed and who underwent a blood transfusion after a drop in the hemoglobin from 12 g/DL on admission to 7.5 g /dL, can your documentation of anemia be further specified as an acute blood loss anemia? Please document your response in the health record or below accompanied by clinical substantiation.

Yes ______________

No ______________

Other ____________

Clinically Undetermined ____________

Name: ___________________          Date:__________

Rationale: In this example, a yes/no query is not appropriate for specifying the type of anemia. A multiple-choice or open-ended query is a better option.

Non-Compliant Example 3

Clinical Scenario: In the ED, a foley catheter was inserted for the patient with dysuria and elevated WBCs that was removed two days after admission. The cultures were positive for E.coli and the progress note reflect a catheter associated urinary tract infection (CAUTI) and this was coded. Quality has requested review of the HAC condition to ensure it should be coded as it does not meet the CDC definition for CAUTI.

Query: The quality department has indicated that your documented diagnosis of CAUTI does not meet the CDC definition which impacts the Hospital Acquired condition statistics for your profile as well as the hospital. Does your patient have a catheter associated urinary tract infection?

Yes ____________

No ______________

Other ___________

Clinically Undetermined _________________

Name: ___________________          Date:__________

Rationale: This query is inappropriate as it explains the impact of the addition or removal of the diagnosis for the physician and hospital profiles. This query questions the physician’s clinical judgment which may be more appropriate in an escalation policy and/or physician education regarding the CDC definition of CAUTI.

For more content on clinical documentation improvement topics, check out the Journal of AHIMA blog “Documentation Detective.” This monthly blog discusses the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.


  1. if aortic atherosclerosis is mentioned can we code i70.0 or not,coudld you please guide me on this

  2. We have providers that do excisions of lesions and debridements and they leave off the dimensions. Can we ask the provider to add the dimensions in for more accurate coding?

  3. Wondering any issues that have come up with AI/NLP programs and compliance? when queries required “choices” and NLP makes a suggestion of one diagnosis, is there any reason for concern from an audit perspective? example- nlp suggest and prompts doctor- do you think severe pcm is valid dx for this patient? if so please add to progress note?… thank you.

  4. I wanted to lodge a complaint angainst doctors and also hospital for surgical operation done in january in 2019 in east london and i want the right procedure to follow.

  5. We are in the process of creating a query process and need direction as this is a fairly new area for me. Our providers are documenting a Health Risk Assessment and often leave documentation off, but instead still code a code. It is my understanding that when there is no documentation or clinical indicators, then a query can not be conducted due to the fact that a coder can not code from a code, and there is no documentation at all to start a query process without leading the provider. Can someone verify this? Thank you in advance!

    1. Risk Adjustment Data Validation for HCC coding( as I understand from your question) is a different process in terms of queries. If condition was coded without supporting documentation and the claim was submitted, the the only way is to educate providers on necessity of supporting info for the future encounter, or submit an addendum. Since condition is already known, it is not a query itself. Vice versa, when the symptoms are documented with clinical indicators suggesting suspected condition corresponding to ICD-10 , compliant query can be submitted .

  6. I am looking for examples of compliant queries for missing or deficient Attending/Teaching Attestations.

  7. Hello All. I am looking for compliant query examples specifically for the outpatient setting? Does anyone have examples of these?

  8. A diagnosis is written in the medical record and no clinical indicators to support the diagnosis, what is the best way to query the physician to give supporting indicators.

    Ex: Post op respiratory failure— documented pt. remained intubated due to difficult airway. Extubated POD 1 without complications

  9. I am new to the Coding and Billing world, finishing in Dec2016, I am new to the whole process of query and the likes, this has been very helpful in getting started on my class project.
    Thank you

  10. We are doing a survey at our facility and going through a question.Please clarify if the physician queries can be addressed and answered by the RESIDENTS irrelevant if concurrent or retrospective queries.
    thank you

    1. Queries should be sent to the “responsible” practitioner. In general, the resident is under the direct supervision of a teaching physician who is ultimately responsible. A bill sent to CMS will be under the teaching MD’s number, not the resident’s. Per guidelines, Residents documentation can be reported, as long as there is no conflicting documentation from the attending. (Who would in general be a teaching physician).. If you query the resident, the teaching MD would never have the opportunity to review/revise, and yet you’d be billing CMS under the teaching MD’s number. The query would be best sent to the attending MD/teaching/MD/etc.

      Of note though, there are some states where residents late in the program are allowed to operate independently and bill Medicare under their own number. Where they are the true responsible practitioner, a query to them would be appropriate.

  11. Dear AHIMA,
    Can coders use a multiple choice format when asking the physician a clinical question with no documentation of a diagnosis or should we use a open ended query.


    Clinical indicators include shortness of breath, increase BNP, edema and a ECHO which shows a EF of 25%. Treatment of IV 80 mg of Lasix.

    Acute Systolic CHF
    Acute on chronic Systolic CHF
    Acute Diastolic CHF
    Acute on Chronic Diastolic CHF
    Unable to determine

    Your guidance will be helpful! Thanks

    1. I would like an answer to this question as well. We have a CHF query similar to this. I am new to CDI and want to query correctly.
      Thank you for the feedback.

      Patricia French

      1. The query above is actually asking 2 questions. First is the diagnosis itself, and second is the acuity.

        At our facility we can provide the acuity options from ICD-10 in a query, but would not “assume” the presence of CHF in all multiple choice options when that diagnosis had not yet been made by an MD. Because the above query does, it would be considered a leading query at our facility.

        In general, there’s a larger best practices goal that the physician should document the diagnosis, and not merely confirm a diagnosis entered by CDI/HIM. In the situation described, the physician doesn’t appear to have ever documented CHF.

        1. Jonathan’s response is perfect.

  12. When formulating a query, would it be leading to include: “for accurate ICD-9 coding, SOI and ROM reflection, please clarify” wording in the Query introduction?

    1. I say the same things using language ‘ clarify to allow for accurate classification’ and ‘best represent the complexity of the patient’s condition presentation’. This is not as obvious a query for coding & reimbursement.

  13. In reference to Robbin and Becky’s questions, my understanding is that if the query response becomes part of the legal health record, it should be released with the request made by the RAC for documentation. If the query is maintained as a business document and not as part of the LHR, there would be no documentation for the RAC to review and an addendum should be made.

    We’ve gone through different methods of making sure it is part of the LHR. We’ve scanned when on paper and now that it is electronic, the question and answer are pulled into the LHR preventing the need for an addendum. Since the answer oftentimes leaves out the context of the question and relevant clinical indicators documented by the coder, we include both.

  14. My question is the same as Becky’s 2/8/13. If the physician documents a diagnosis on the Query form which is part of the medical record, does the physician have to amend his/her Discharge Summary to include the documentation from the Query form?

  15. Julian and Sandy, thank you for your responses. We are working on developing additional examples that will appear at a future date.

  16. Can you provide examples of leading vs. non-leading for outpatient querying in regards to medically necessary diagnosis?

  17. When you infer that the doctor can either answer on the query or in the medical record: Can you further clarify what is expected on the discharge summary? For instance: If the MD either marks the query appropriately or documents in the record does he have to give another summary on the discharge? I’ve been instructed that this is the only place RAC auditors will look (e.g. discharge summary).

    1. I always ask for both a brief response to the query AND in most cases, documentation within the record to clearly describe how they came to this conclusion, clinical indicators, evaluation, treatment, response to treatment etc. To best represent the value of physician critical thinking and interventions, we urge them to “think in ink’ and ‘show their work’. This is a valuable tool in coordination of care.

  18. Can you please give an example of a compliantly worded query base on non compliant example #3. Also can you help define what an escalation policy is? Thanks for your help.

    1. USE YOUR UWN WORDING – Because the patient presented with urinary symptoms, there is some indication that the UTI was present on admission prior to catheterization. Was there a catheter procedure prior to presentation in the ED? What would the physician describe as UTI time of onset in relation to time of catheterization?

  19. Thank you for providing these example query forms. This is going to be very helpful.

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