What is a physician query?

A physician query is a communication tool used to clarify documentation in the medical record to ensure accurate code assignment and capture of the patient’s clinical picture.

Why is learning about query composition important for coders?

Coders and CDI professionals need to know how to compose queries correctly to avoid compliance risks, ensure coding accuracy, and promote proper reimbursement.

What are the benefits of taking this course?

You'll understand when and how to issue queries, how to phrase them compliantly, and where query opportunities most often arise. You'll also gain clarity on key policy elements like retention, timing, and the use of prior encounters.

Course: Identifying Query Opportunities: Sepsis, Pneumonia, Acute Respiratory Failure and Acute Tubular Necrosis -HIAlearn

Identifying Query Opportunities: Sepsis, Pneumonia, Acute Respiratory Failure and Acute Tubular Necrosis is an online, self-paced course built for coders who review clinical documentation and need to quickly spot when a query is appropriate. Designed for inpatient coding teams and documentation review workflows (and helpful for outpatient and profee coders who see these diagnoses regularly), this course walks through common documentation gaps, clinical indicators, diagnostic criteria, and treatment clues that signal opportunities to clarify type, acuity, severity, organism, or linkage for four high-impact conditions.

Through condition-focused lessons and case studies, learners strengthen documentation-to-code decision-making for sepsis (including infection source, organ dysfunction, and Sepsis-3 and SOFA indicators), pneumonia (including type, causative organism, and aspiration risk factors), acute respiratory failure (including hypoxemic versus hypercapnic criteria and respiratory support documented), and acute tubular necrosis (including KDIGO acute kidney injury criteria, nephrotoxic exposures, and persistence of renal dysfunction). By the end of the course, coders will be better prepared to identify compliant query opportunities that support accurate reporting and reduce back-and-forth clarifications that slow down final coding.

Included Lessons:

Introduction
Sepsis
Pneumonia
Acute Respiratory Failure
Acute Tubular Necrosis

Key Takeaways

Understand the role of compliant queries in supporting accurate diagnosis reporting and documentation integrity.
Recognize clinical indicators and treatment patterns that suggest sepsis, pneumonia, acute respiratory failure, or acute tubular necrosis.
Differentiate between localized infections and systemic conditions requiring provider clarification.
Apply Sepsis-3 and SOFA criteria to identify potential sepsis query opportunities.
Identify appropriate query scenarios for pneumonia type, organism, and complications.
Distinguish between hypoxemic and hypercapnic acute respiratory failure and their diagnostic thresholds.
Apply KDIGO criteria to identify possible acute tubular necrosis versus acute kidney injury.
Formulate compliant, non-leading queries supported by clinical evidence and treatment documentation.

Benefits of Taking this Course

Improved ability to identify high-impact query opportunities for CC and MCC conditions.
Greater confidence in reviewing complex clinical documentation and supporting diagnoses.
Enhanced understanding of how documentation affects DRGs, quality measures, and severity capture.
Stronger alignment with AHIMA and ACDIS compliant query standards.
Reduced risk of missed diagnoses due to incomplete or unclear provider documentation.
Practical application through real-world case studies and clinical scenarios.

Who should take this course?

This course is designed for inpatient coders, CDI specialists, auditors, compliance professionals, and healthcare documentation reviewers who are responsible for identifying documentation gaps and supporting accurate diagnosis reporting.

Does this course cover clinical criteria and treatment requirements?

Yes. The course reviews clinical indicators, diagnostic criteria, and common treatment approaches for each condition, helping learners link documentation, clinical evidence, and coding requirements.

Are real-world examples included?

Yes. Each condition includes case studies that allow learners to apply concepts and practice identifying appropriate query opportunities in realistic clinical scenarios.

About Our Medical Coding Courses

HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a flexible, online education platform designed for today’s coders. With a growing catalog of AHIMA and AAPC-approved coding courses, HIAlearn supports both beginners and experienced coders looking to build confidence, accuracy, and CEU credits.

Courses are available across various coding types including CPT, E/M, ICD-10-CM, and ICD-10-PCS, and are designed for multiple specialties including inpatient, outpatient, profee, and CDI.

To stay up to date, coders can explore our Coding Updates hub for the latest ICD-10-CM, ICD-10-PCS, CPT, and IPPS changes. HIAlearn also supports organizations with group discounts and scalable team access, promoting accuracy, compliance, and continuous professional development across departments.