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CDI Query Templates

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📝 CDI Query Templates — Compliant Query Language Library

Purpose

This note contains ready-to-use, compliance-vetted query templates organized by DRG trigger category. All queries follow AHIMA and ACDIS guidelines: non-leading, multiple-choice format, clinically grounded, and documentation-supported. Never issue a query to chase a DRG — issue it to resolve a documentation gap.

⚖️ Query Compliance Rules — Know Before You Query

Non-Negotiable Compliance Standards

Per AHIMA Practice Brief and ACDIS CDI guidelines, every query must:

  • Present clinically reasonable options only — do not include diagnoses not supported by the record
  • Always include “Clinically undetermined” as a choice
  • Be based on clinical indicators documented in the chart — list them explicitly
  • Never reference DRG, reimbursement, or payment in the query text
  • Be physician/provider-directed — coders cannot self-determine
  • Be documented and trackable — concurrent or retrospective, both are valid
Query FormatUse Case
Multiple choicePreferred; provider selects or writes in response
Yes/NoAcceptable only when the single issue is binary
Open-endedUse when the options are truly unknown; least preferred

🗂️ Query Index

  1. 🫘 Sepsis & Infection Queries
  2. 🫁 Respiratory Failure Queries
  3. 🧪 Acute Kidney Injury (AKI) Queries
  4. 🧠 Encephalopathy Queries
  5. 🍽️ Malnutrition Queries
  6. 🩸 Anemia Queries
  7. 💉 Fluid & Electrolyte Queries
  8. 🫀 Heart Failure Queries
  9. 🤕 Pressure Injury / Wound Queries
  10. 🦠 Organism Specificity Queries
  11. 🔪 Procedure Clarification Queries
  12. 🏥 Specialty-Specific Queries — Urology, ENT, Ophthalmology

🫘 Sepsis & Infection Queries

Template S-1: Sepsis Clarification (General)

Clinical Indicators to Document Before Sending:

  • Fever / hypothermia
  • Tachycardia, tachypnea
  • Elevated WBC or bandemia
  • Suspected or confirmed infection source
  • Antibiotic initiation

Query Text: The patient was admitted with [clinical indicators: e.g., WBC 18.2, temp 38.9°C, HR 118, suspected UTI source, broad-spectrum antibiotics initiated on DOA]. Based on the clinical presentation, please clarify whether the patient’s condition is best described as:

☐ Sepsis (infection + systemic response) ☐ Severe Sepsis (sepsis + acute organ dysfunction — specify organ: _________) ☐ Septic Shock (sepsis + vasopressor-refractory hypotension) ☐ Systemic Inflammatory Response Syndrome (SIRS) without sepsis ☐ Infection without SIRS criteria ☐ Clinically undetermined

If sepsis is present, please identify the causative organism if known: _____________ If sepsis is present, please identify the source/site: _____________

DRG Impact: A41.xx = MCC; R65.20 Severe sepsis = MCC; R65.21 Septic shock = MCC

Template S-2: Urosepsis Clarification

"Urosepsis" Has No ICD-10-CM Code

When a provider documents “urosepsis,” a query is required. Coding only N39.0 misses the MCC.

Query Text: The term “urosepsis” was documented in the [note type, date]. ICD-10-CM does not recognize “urosepsis” as a standalone diagnosis. Based on the clinical presentation [list indicators], please clarify:

☐ Sepsis due to urinary tract infection — code to A41.9 or organism-specific A41.xx + N39.0 ☐ Urinary tract infection with SIRS response — N39.0 + R65.10/R65.11 ☐ Urinary tract infection without sepsis — N39.0 ☐ Clinically undetermined

Template S-3: Sepsis Source / Organism Specificity

Query Text: Sepsis is documented. Blood/urine cultures resulted [organism, date]. Please clarify the causative organism for accurate coding:

☐ Sepsis due to Staphylococcus aureus — A41.01 (MSSA) / A41.02 (MRSA) ☐ Sepsis due to Streptococcus — A41.1 ☐ Sepsis due to Escherichia coli — A41.51 ☐ Sepsis due to Pseudomonas — A41.52 ☐ Sepsis due to other gram-negative organism — A41.59 ☐ Sepsis, organism unspecified — A41.9 ☐ Clinically undetermined

🫁 Respiratory Failure Queries

Template R-1: Acute Respiratory Failure

Clinical Indicators:

  • SpO₂ < 90% on room air
  • PaO₂ < 60 mmHg or PaCO₂ > 50 mmHg on ABG
  • Supplemental O₂ requirement escalation
  • Mechanical ventilation initiated

Query Text: The patient required [supplemental oxygen / BiPAP / mechanical ventilation] during this admission. ABG results on [date]: [values]. Please clarify:

☐ Acute Respiratory Failure with Hypoxia — J96.01 ☐ Acute Respiratory Failure with Hypercapnia — J96.02 ☐ Acute Respiratory Failure, unspecified — J96.00 ☐ Acute-on-Chronic Respiratory Failure with Hypoxia — J96.21 ☐ Acute-on-Chronic Respiratory Failure with Hypercapnia — J96.22 ☐ Chronic Respiratory Failure — J96.10-J96.12 ☐ Respiratory Insufficiency / Difficulty, not failure ☐ Clinically undetermined

DRG Impact: J96.01, J96.02 = MCC

Template R-2: Post-Op Respiratory Failure

Query Text: The patient required prolonged ventilatory support / re-intubation following [procedure, date]. Please clarify whether this represents:

☐ Postprocedural respiratory failure — J95.821 (acute) / J95.822 (acute-on-chronic) ☐ Acute respiratory failure unrelated to procedure — J96.0x ☐ Expected post-op ventilatory management, not failure ☐ Clinically undetermined

🧪 Acute Kidney Injury (AKI) Queries

Template K-1: AKI Clarification

Clinical Indicators:

  • Rise in creatinine ≥ 0.3 mg/dL within 48 hrs or ≥ 1.5× baseline within 7 days
  • Decrease in urine output < 0.5 mL/kg/hr for ≥ 6 hrs
  • IV fluid resuscitation, nephrology consult, or Foley monitoring documented

Query Text: The patient’s creatinine on admission was [X] and peaked at [Y] on [date]. [Additional indicators: IV fluids, nephrology consult, etc.] Please clarify:

☐ Acute Kidney Injury (AKI) — N17.9 ☐ Acute-on-Chronic Kidney Disease — N18.xx + N17.9 ☐ Pre-renal azotemia — N17.0 ☐ Chronic Kidney Disease without acute injury — N18.xx ☐ Contrast-induced nephropathy — N14.11 ☐ Baseline elevated creatinine, no acute process ☐ Clinically undetermined

DRG Impact: N17.9 = MCC across most DRGs

Template K-2: CKD Stage Specificity

Query Text: CKD is documented. The most recent GFR was [value] on [date]. Please document the CKD stage:

☐ CKD Stage 1 — N18.1 (GFR ≥ 90) ☐ CKD Stage 2 — N18.2 (GFR 60-89) ☐ CKD Stage 3a — N18.31 (GFR 45-59) ☐ CKD Stage 3b — N18.32 (GFR 30-44) ☐ CKD Stage 4 — N18.4 (GFR 15-29) — CC ☐ CKD Stage 5 — N18.5 (GFR < 15, not on dialysis) — MCC ☐ ESRD on dialysis — N18.6 — MCC ☐ Clinically undetermined

🧠 Encephalopathy Queries

Template E-1: Encephalopathy Type

Clinical Indicators:

  • Altered mental status, confusion, disorientation
  • Abnormal lab values (ammonia, BMP, LFTs, drug levels)
  • Neuro consult or brain imaging performed

Query Text: The patient exhibited [altered mental status / confusion / agitation] during this admission. [List relevant labs/imaging]. Please clarify the etiology of the encephalopathy:

☐ Metabolic Encephalopathy — G93.41 — MCC ☐ Toxic Encephalopathy (medication/substance) — G92.9 — MCC ☐ Hepatic Encephalopathy — K72.90 or K72.91 — MCC ☐ Hypoxic Encephalopathy — G93.1 — MCC ☐ Septic Encephalopathy — G93.41 + sepsis codes ☐ Delirium (specify: hyperactive / hypoactive / mixed) — F05 ☐ Dementia with behavioral disturbance ☐ Clinically undetermined

DRG Impact: Most encephalopathy types = MCC; delirium = CC in many DRGs

🍽️ Malnutrition Queries

Template M-1: Malnutrition Severity

Clinical Indicators:

  • BMI < 18.5, or significant weight loss (>5% in 1 month, >10% in 6 months)
  • Albumin < 3.0 g/dL, prealbumin < 15 mg/dL (used as supporting evidence)
  • Nutrition consult placed; dietitian assessment documents malnutrition
  • Oral intake severely reduced; tube feeding initiated

Query Text: Nutrition assessment on [date] documented [albumin X, BMI Y, weight loss Z%]. A dietitian consultation was placed and findings are as noted in [note]. Please clarify the degree of malnutrition:

☐ Severe (protein-calorie) malnutrition — E43 — MCC ☐ Moderate malnutrition — E44.0 — CC ☐ Mild malnutrition — E44.1 — CC ☐ Cachexia — R64 — CC ☐ Abnormal weight loss without malnutrition — R63.4 ☐ No malnutrition ☐ Clinically undetermined

🩸 Anemia Queries

Template A-1: Anemia Type Clarification

Query Text: The patient’s hemoglobin on admission was [X]. [Treatment: transfusion / iron infusion / B12 / EPO] was administered. Please clarify the type of anemia:

☐ Acute blood loss anemia — D62 — CC ☐ Chronic blood loss anemia — D50.0 — CC ☐ Iron deficiency anemia — D50.9 — CC ☐ Anemia due to CKD — D63.1 — CC ☐ Anemia due to malignancy — D63.0 — CC ☐ Aplastic anemia — D61.9 — MCC ☐ Anemia, unspecified — D64.9 — CC ☐ Clinically undetermined

💉 Fluid & Electrolyte Queries

Template F-1: Hyponatremia

Query Text: Sodium on [date] was [value]. IV sodium replacement / fluid restriction was initiated. Please clarify:

☐ Hyponatremia — E87.1 — MCC when severe/treated aggressively ☐ Dilutional hyponatremia (SIADH) — E22.2 — CC ☐ Hypovolemic hyponatremia ☐ Lab value, not clinically significant ☐ Clinically undetermined

Template F-2: Dehydration / Volume Depletion

Query Text: The patient received [X liters IV fluids]. BUN/Cr ratio was [Y]. Please clarify:

☐ Volume depletion / Dehydration — E86.0 — CC ☐ Hypovolemia — E86.1 — CC ☐ IV fluids for maintenance, not for volume deficit ☐ Clinically undetermined

🫀 Heart Failure Queries

Template H-1: Heart Failure Type & Acuity

Query Text: Echocardiogram on [date] showed EF [X%]. BNP was [Y]. [Diuresis/IV Lasix/BiPAP] was initiated. Please clarify:

☐ Acute Systolic Heart Failure — I50.21 — MCC ☐ Chronic Systolic Heart Failure — I50.22 — CC ☐ Acute-on-Chronic Systolic Heart Failure — I50.23 — MCC ☐ Acute Diastolic Heart Failure — I50.31 — MCC ☐ Chronic Diastolic Heart Failure — I50.32 — CC ☐ Acute-on-Chronic Diastolic Heart Failure — I50.33 — MCC ☐ Heart Failure with Preserved EF (HFpEF) — I50.30-I50.33 ☐ Heart Failure, unspecified — I50.9 — CC ☐ Clinically undetermined

🤕 Pressure Injury / Wound Queries

Template W-1: Pressure Injury Stage

Query Text: Wound care nursing notes and/or wound consult on [date] document a pressure injury at [location]. Please clarify the stage:

☐ Stage 1 — Non-blanchable erythema — L89.xx1 ☐ Stage 2 — Partial thickness skin loss — L89.xx2 — CC ☐ Stage 3 — Full thickness skin loss — L89.xx3 — MCC ☐ Stage 4 — Full thickness tissue loss — L89.xx4 — MCC ☐ Unstageable — L89.xx0 — MCC ☐ Deep tissue pressure injury — L89.xx6 — CC ☐ Clinically undetermined

(Site: sacral / coccyx / heel / hip / other: _________)

POA Indicator Critical Here

Stage 3/4/Unstageable pressure injuries are HACs if they develop during the stay (POA = N). This removes MCC status AND triggers HAC penalty. Accurate POA documentation is essential.

🦠 Organism Specificity Queries

Template O-1: MRSA vs MSSA

Query Text: Culture results on [date] confirmed Staphylococcus aureus. Sensitivity panel showed [MRSA/MSSA]. Please confirm:

☐ Infection due to MRSA — use Z16.11 (resistance) + B95.62 (MRSA as cause) ☐ Infection due to MSSA — B95.61 ☐ Colonization only, not active infection — Z22.322 ☐ Clinically undetermined

🔪 Procedure Clarification Queries

Template P-1: Tracheostomy Indication (ENT/Critical Care)

Query Text: The patient underwent tracheostomy on [date]. Please clarify the clinical indication:

☐ Prolonged mechanical ventilation — anticipated > 14 days ☐ Upper airway obstruction — specify etiology: _______ ☐ Airway protection due to neurological deficit ☐ Weaning failure from endotracheal intubation ☐ Other: _______ ☐ Clinically undetermined

DRG Impact: Tracheostomy with MV ≥ 96 hrs → Pre-MDC DRG 003 (RW ≈ 18+)

Template P-2: Principal Procedure Clarification

Query Text: Multiple procedures were performed during this admission: [list procedures]. Please clarify which procedure was performed for the definitive treatment of the principal diagnosis and/or was the most resource-intensive:

☐ [Procedure A] — [date] ☐ [Procedure B] — [date] ☐ Both equally principal ☐ Clinically undetermined

🏥 Specialty-Specific Queries — Urology, ENT, Ophthalmology

🫘 Urology

Query U-1: Obstructive Uropathy + AKI

The patient presented with [hydronephrosis / ureteral obstruction / BPH with retention]. Creatinine was [X baseline] → [Y peak]. Please clarify:

☐ Obstructive nephropathy with AKI — N13.30 + N17.9 ☐ Hydronephrosis without AKI — N13.30 ☐ BPH with urinary retention — N40.1 ☐ Clinically undetermined

Query U-2: Cystostomy vs Nephrostomy Intent

Drainage procedure was performed on [date]. Please clarify the primary intent:

☐ Suprapubic catheter — temporary vs permanent ☐ Nephrostomy — therapeutic vs diagnostic ☐ Combined drainage approach ☐ Clinically undetermined

👂 ENT / Otolaryngology

Query ENT-1: Airway Obstruction Etiology

The patient required [intubation / tracheostomy / emergent airway management] on [date]. Please clarify the primary cause of airway compromise:

☐ Angioedema — T78.3XXA — MCC ☐ Epiglottitis — J05.10 / J05.11 ☐ Laryngeal edema — J38.4 ☐ Post-operative edema / hematoma — J95.xx ☐ Malignancy-related obstruction — specify: ______ ☐ Clinically undetermined

Query ENT-2: Neck Dissection Extent

Operative report documents lymph node dissection of the neck on [date]. Please clarify the extent:

☐ Radical neck dissection — 38720 equivalent PCS ☐ Modified radical neck dissection ☐ Selective neck dissection — specify levels: _______ ☐ Sentinel lymph node biopsy only — 38900 equivalent ☐ Clinically undetermined

👁️ Ophthalmology

Query OPH-1: Endophthalmitis Etiology

The patient was admitted for intraocular infection. Please clarify:

☐ Acute endophthalmitis, post-procedural — H59.031-H59.039 ☐ Purulent endophthalmitis — H44.001-H44.009 ☐ Panophthalmitis — H44.011-H44.019 ☐ Sympathetic uveitis ☐ Clinically undetermined

Query OPH-2: Diabetic Eye Disease Specificity

Diabetic retinopathy is documented with [laser / injection / vitrectomy] performed. Please clarify:

☐ Proliferative diabetic retinopathy with tractional detachment — E11.3511 right / E11.3512 left ☐ Proliferative diabetic retinopathy without detachment — E11.3531 ☐ Severe non-proliferative diabetic retinopathy — E11.3491 ☐ Moderate non-proliferative — E11.3392 ☐ Diabetic macular edema — specify: ______ ☐ Clinically undetermined

🔗 Related Notes

Templates are compliance frameworks — always populate clinical indicators from the actual chart before sending. Never send a blank template.

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