CDISs are not allowed to LEAD the HCP
. That is, only the HCP
may diagnose a patient she is taking care of, so even a CDIS
with clinical experience may not formally make a diagnosis. So she isn’t permitted to smack a doc upside the head and say, “Just write ‘encephalopathy’!”
Here are acceptable reasons to generate a query:
- Conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent documentation. Let me add “Dragon gobbledygook” as an additional reason now.
- Clinical indicators, diagnostic evaluation, medical treatment, or a procedure which seem to suggest a definitive diagnosis which is not documented in a codable format
- A diagnosis which does not seem to have clinical validation
- Question regarding present on admission indicator assignment
The CDIS should either be giving information and asking if there is a corresponding diagnosis, or giving multiple choices, including some variation on ‘clinically undetermined’ and ‘other.’ Rather than defaulting on one of these because it is easiest, the HCP should really consider the query and try to answer. If they don’t understand what is being asked, it is permissible to ask questions for clarification.