Establish the Relationship Between Conditions

ICD-10-CM Sample Queries

Note: These sample queries were adapted from The CDI Specialist’s Guide to ICD-10, created and donated by Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro, Inc., in Danvers, Mass.

Establish the relationship between conditions

Sample 1

The diagnoses of alcohol dependence and anxiety disorder are both listed as discharge diagnosis. Can you please clarify in an addendum to the discharge summary if a relationship exists between these diagnoses as follows . . .

There is no relationship between alcohol dependence and anxiety disorder

The anxiety disorder is secondary to the alcohol dependence

Unable to determine

Other ______

Note: This query is based on recent guidance allowing expansion of yes/no queries from ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice."

Sample 2

The diagnosis of sepsis appears within the progress notes on _____. The diagnosis of acute renal failure was documented today. Please clarify what, if any, relationship between the sepsis and acute renal failure in the next progress note and/or discharge summary.

No relationship

The acute renal failure is secondary to the sepsis

Unable to determine

Other ______

MD signature ______date ______

Note: This query is based on recent guidance allowing expansion of yes/no queries from ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice."

Sample 3

Ms. Jones has a history of atherosclerosis and was admitted with gangrene of the great right toe. Please clarify what, if any, relationship exists between the atherosclerosis and gangrene in the next progress note and/or discharge summary.

No relationship

The gangrene is secondary to the arthrosclerosis

Unable to determine

Other ______

MD signature ______date ______

Sample 4

The admission note lists a history of diabetes type 2 and the patient is being admitted with gangrene of the left great toe. Can you please clarify in the progress notes and/or discharge summary if any of the following relationships exist between these conditions:

The gangrene is not related to the patient’s diabetes

The gangrene is secondary to diabetes

Unable to determine

Other ______

Alternative Sample 4

No, the gangrene is not related to the patient’s diabetes

Yes, the gangrene is secondary to the diabetes

Unable to determine

Other ______

MD signature ______date ______

Note: This query is based on recent guidance allowing expansion of yes/no queries from ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice."

Sample 5

In the H&P the patient is noted to have a history of CAD and takes Lipitor for hyperlipiemia. Please clarify what, if any, relationship between the CAD and the hyperlipidemia in the next progress note and/or discharge summary.

No relationship

The CAD is secondary to the hyperlipdemia

Unable to determine

Other ______

Note: This query is based on recent guidance allowing expansion of yes/no queries from ACDIS/AHIMA "Guidelines for Achieving a Compliant Query Practice."

Alternative Sample 5

In the H & P the patient is noted to have a history of CAD and takes Lipitorfor hyperlipiemia. Is there a relationship between the CAD and the hyperlipidemia?

No, there is not a relationship

Yes, the CAD is secondary to the hyperlipdemia

Unable to determine

Other ______

MD signature ______date ______

Capture causative organism

Sample 1

The patient has a diagnosis of an infectious condition, please state the associated organism, if known, or the likely organism based on presentation, epidemiology and response to treatment. Positive culture results are not necessary to specify an organism:

•Known organism - specify: ______

•Evidence of: ______

•Unable to determine

•Other ______

MD signature ______date ______

Sample 2

The diagnosis of ______appears in the ______. Please document the known or suspected associated organism. A blood culture is not required to identify the organism as it may be identified based on patient’s history, presentation and response to treatment.

Streptococcus

Group A  Group BPneumoniaeOther: ______

Enterococcus

Staphylococcus

Other: ______

Methicillin Staphylococcus aureus

SusceptibleResistant

Unable to determine

Other: ______

*can add other B96 and B97 organisms

Capture missing diagnosis

Sample 1

Mr. Smith has a diagnosis of encephalitis documented in the 1/1/11 progress notes. Documentation also notes an altered level of consciousness and “confusion.” Please determine if any of the following diagnoses, which are commonly associated with encephalitis, is supported by these clinical indicators in the next progress note and/or the discharge summary.

Alcoholic encephalopathy

Toxic encephalitis

Toxic encephalopathy

Unable to determine

Other ______

Sample 2

Mr. Smith has a history of vascular dementia and is being medicated with Lorazepam. Can you please clarify the condition which is being treated with this medication in the next progress note and/or discharge summary?

Vascular dementia with aggressive behavior

Vascular dementia with combative behavior

Vascular dementia with violent behavior

Vascular dementia with other behavioral disturbance: ______

Unable to determine

Other: ______

Sample 3

Ms. Smith was admitted for AMS. Her CT was negative for changes; however, she was identified as having a UTI. Ms. Smith does not have a history of dementia. Ms. Smith remained altered despite treatment with Ativan on 1/1/11. Based on these clinical findings please clarify in your next progress note and/or the discharge summary if any of the following diagnoses are associated with the AMS and occasioned the admission.

Metabolic encephalopathy

Other encephalopathy

Unable to determine

Other ______

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