In CDI practice, how is a query typically structured to improve documentation?

• A. A concise, non-leading question asking for clarification or addition of specific diagnoses, POAs, or modifiers to reflect clinical reality.
• B. A directive prompt to code a specific diagnosis.
• C. A yes/no confirmation of coding accuracy.
• D. A broad narrative request without specificity.

Answer: (A)

Conciseness and neutrality guide how a CDI query is typically structured. A well-crafted query asks for clarification or an addition to the chart in a specific, non-leading way—for example, requesting a more precise diagnosis, the present-on-admission status, or the appropriate modifiers that accurately reflect what happened clinically. This approach helps ensure the documentation truly mirrors the patient’s condition, supports correct coding, and improves data quality without nudging clinicians toward a particular code.

Directing the coder to pick a specific diagnosis pushes toward a predetermined code rather than confirming what’s documented; a yes/no confirmation doesn’t resolve ambiguity or add missing detail; and a broad, narrative request is too vague to drive meaningful improvement.