Certified Inpatient Coding (CIC) Practice Exam

When should a coder consider using a provider query for patient documentation?

1. Documentation is legible but incomplete

2. Documentation is unclear or incomplete

3. Documentation provides a diagnosis without clinical validation

4. Documentation includes all necessary information

The correct answer is: Documentation provides a diagnosis without clinical validation

A provider query is typically necessary when there is uncertainty regarding the clinical significance of documented conditions or diagnoses. In this context, the correct answer highlights the importance of clinical validation for a diagnosis provided in the documentation. When documentation includes a diagnosis that lacks sufficient clinical validation, it raises questions about the accuracy and appropriateness of that diagnosis as it relates to the patient's treatment and the coding guidelines. A coder should seek clarification from the provider to ensure that the diagnosis is supported by the patient's medical condition and clinical findings. This process helps maintain the integrity of coding and ensures that the healthcare services are accurately reflected in the health records. The other options suggest situations where documentation might be problematic; however, for a provider query to be warranted, there needs to be a specific concern about the diagnosis lacking clinical validation, which is why that aspect is emphasized. In terms of completeness or legibility, if the documentation is unclear but does imply a valid diagnosis or if it is fully documented, the need for a query would not be necessary in those contexts. Thus, using a provider query when a diagnosis is presented without clinical justification is an essential step for ensuring accurate patient records and coding compliance.