Queries should be performed by which of the following?

Queries should be performed by which of the following?

• A. Nurses
• B. CDI professionals
• C. Physicians
• D. IT staff

Answer: (B)

In clinical documentation improvement, the person who initiates and handles queries is the CDI professional, because they specialize in identifying ambiguous or missing documentation and know how to phrase questions in a compliant, non-leading way to elicit precise clinical information from physicians. This role requires understanding coding rules (ICD-10-CM/PCS), documentation standards, and payer guidelines, so the queries accurately support correct coding, severity of illness, and case mix. While physicians may respond to queries and IT staff may support the systems used to track them, the active task of performing and drafting the queries is best handled by the CDI professional. Nurses contribute to the documentation narrative, but the formal querying process is a specialized responsibility of the CDI role.

In clinical documentation improvement, the person who initiates and handles queries is the CDI professional, because they specialize in identifying ambiguous or missing documentation and know how to phrase questions in a compliant, non-leading way to elicit precise clinical information from physicians. This role requires understanding coding rules (ICD-10-CM/PCS), documentation standards, and payer guidelines, so the queries accurately support correct coding, severity of illness, and case mix. While physicians may respond to queries and IT staff may support the systems used to track them, the active task of performing and drafting the queries is best handled by the CDI professional. Nurses contribute to the documentation narrative, but the formal querying process is a specialized responsibility of the CDI role.