Study guide
9.2 Verbal Queries and Required Documentation
Certified Clinical Documentation Specialist CCDS
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1 Introduction & Exam Overview
1.1 Current Exam Facts 1.2 Eligibility Pathways and the 2,000-Hour Year 1.3 Allowed Resources and Test-Day Rules 1.4 Recertification, Fees, and How This Guide Maps the Eight Domains
2 IPPS Foundations
2.1 How IPPS Works and How CMS Updates It 2.2 MS-DRG Assignment, Relative Weights, and Grouping 2.3 Provider and Clinical Staff Documentation Duties under IPPS
3 Severity, CMI, Medical Necessity, and Oversight
3.1 CC versus MCC Recognition and CC Exclusion Lists 3.2 Case Mix Index and Why CDI Tracks It 3.3 Two-Midnight Rule, Medical Necessity of Setting, and Principal Diagnosis 3.4 MAC, RAC, CERT, OIG, and Denial-Vulnerable Practices
4 Nervous and Respiratory System CDI
4.1 Nervous System Conditions for CDI 4.2 Acute and Chronic Respiratory Failure, ABGs, and Ventilation Support 4.3 Pneumonia, COPD, PE, Pleural Effusion, and Respiratory Infections
5 Circulatory, Digestive, Hepatobiliary, Musculoskeletal, and Skin CDI
5.1 Circulatory Disorders 5.2 Digestive and Hepatobiliary Disorders 5.3 Musculoskeletal and Skin
6 Endocrine, Nutrition, Kidney, and Hematologic CDI
6.1 Diabetes, Dehydration, and Obesity 6.2 Malnutrition Criteria, Severity, and Audit Risk 6.3 AKI, CKD Staging, UTI, and Urinary Stones 6.4 Anemia, Coagulation, Sickle Cell, Lymphoma, and Leukemia
7 Infectious Disease, Other MDCs, and Clinical Indicator Tools
7.1 Sepsis, Severe Sepsis, Postoperative and Other Infections 7.2 Mental, Substance Use, Injuries/Toxicology, and HIV-Related Conditions 7.3 Medications, Diagnostic Tests, and Abbreviations as Clinical Indicators
8 Health Record Elements and Query Triggers
8.1 Which Record Elements Support Diagnosis and Procedure Codes 8.2 Attending versus Radiologist, Pathologist, and Other Providers 8.3 When a Physician Query Is Warranted 8.4 When Queries Are Not Appropriate
9 Query Timing, Verbal Queries, Formats, and Clinical Indicators
9.1 Concurrent, Retrospective, Pre-Bill, and Prospective Timing 9.2 Verbal Queries and Required Documentation 9.3 Open-Ended, Multiple-Choice, and Yes/No 9.4 Clinical Indicators and How to Source Them
10 Compliant Query Practice and Clinical Validation
10.1 Compliant versus Leading and Other Noncompliant Queries 10.2 ACDIS/AHIMA 2026 Guidelines for Achieving a Compliant Query Practice 10.3 Clinical Validation and Diagnoses without Clinical Support
11 CDI Program Metrics
11.1 Productivity, Query Volume, and Provider Response Rates 11.2 CMI, CC/MCC Capture, and High-Frequency DRGs 11.3 SOI/ROM as CDI Program Performance Metrics
12 Physician Metrics, PEPPER, Forecasting, and Public Data
12.1 Measuring Physician Documentation Performance 12.2 PEPPER, Forecasting, Hospital Financial Data, and Public Reporting
13 CDI Roles, Coder Collaboration, and Physician Education
13.1 Roles and Responsibilities of the CDI Specialist 13.2 Coder Roles Working with a CDI Department 13.3 Physician Education Tools, Forms, and Presentations
14 Provider Communication and DRG Reconciliation
14.1 Non-Confrontational Communication and When Verbal Beats Written 14.2 Working DRG versus Final DRG Reconciliation
15 Official Guidelines, Principal Diagnosis, and Secondary Diagnosis
15.1 Official Guidelines, Cooperating Parties, Updates, and AHA Coding Clinic 15.2 Principal Diagnosis Selection 15.3 Secondary Diagnosis Reporting Criteria
16 Sequencing, Coding Conventions, and POA Indicators
16.1 Sequencing When Two Diagnoses Equally Meet PD; Working DRG with Multiple Diagnoses 16.2 Integral Signs/Symptoms, the With Convention, and Uncertain Diagnoses 16.3 Present-on-Admission Indicator Assignment and Payment Impact
17 Hospital-Acquired Conditions, Disposition, and ICD-10-PCS Essentials
17.1 CMS Hospital-Acquired Condition Payment Provision 17.2 Discharge Disposition, Transfer Payment, Principal Procedure, and ICD-10-PCS Essentials
18 Ethics, Privacy, and Leading Queries as Compliance Failures
18.1 ACDIS Code of Ethics and CDI Goals beyond Reimbursement 18.2 HIPAA, Minimum Necessary, and Record Confidentiality 18.3 Leading Queries as a Compliance Failure
19 DRG Creep, OIG Oversight, PEPPER, and the False Claims Act
19.1 DRG Compliance, DRG Creep, and the OIG Work Plan 19.2 PEPPER Compliance Risks and the False Claims Act
20 Mortality Index, Observed-to-Expected Ratios, and Quality Data Sources
20.1 Documentation Impact on Mortality Index (SOI/ROM) 20.2 Mortality Reviews and Observed-to-Expected Ratios 20.3 Abstracted versus Claims-Based Quality Data
21 CMS Quality Programs, PSIs, and Infection versus Complication Codes
21.1 HVBP, HAC Reduction Program, HRRP, 30-Day Mortality, and Hospital IQR 21.2 PSI 90 Components and PSIs beyond the Composite 21.3 Healthcare-Associated Infections versus Complication Codes
9.2 Verbal Queries and Required Documentation
Key Takeaways Explain This Topic AI
Not every hallway conversation is a query; a verbal query asks for clarification on a specific patient encounter
Record date and time, participants, sourced clinical indicators, the nonleading statement, any options offered, and the verbal response
The provider's response must reach the permanent health record before the clarified condition can be coded
If the provider verbally agrees but never documents, seek an addendum or written query and escalate rather than coding from the conversation
Last updated: September 2026
9.2 Verbal Queries and Required Documentation
Quick Answer: Not every hallway chat is a query. A verbal query asks a provider to clarify a specific encounter . Record date and time, people, indicators and source, the nonleading statement, options if any, and the verbal response. That response must reach the permanent health record before coding. If the provider said yes and never wrote it, escalate.
Spoken communication is fast, and inpatient CDI specialists use it every day: a 30-second stop at the nurses' station, a huddle with the intensivist, a peer-to-peer call from a coder. The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice draw a bright line. Not every spoken interaction related to documentation is a verbal query. General discussions of documentation habits and de-identified teaching cases used for education are not queries. A verbal query is a conversation that requests further specificity or clarification for documentation opportunities on a specific patient encounter .
That distinction protects both compliance and relationships. You can still teach a hospitalist how to document heart-failure type in a noon conference without creating a query file. You cannot treat a whispered "it's failure, just put it in" on Mr. Ortiz in 4B as unofficial coding fuel. Once you ask that attending to clarify this chart, you are in query territory, and the 2026 required elements apply whether the medium is spoken, written, or generated by software.
What makes the conversation a query
A verbal query has the same purpose as a written one: to seek clarification of an otherwise unclear record. It may travel from CDI to provider or from peer to peer (coder to CDI, CDI to coder, specialist to attending). Role does not create a loophole. If the speech act is "please clarify this patient's documentation," it must be nonleading , it must present sourced clinical indicators , it must not mention reimbursement or quality outcomes, and it must let the provider keep independent judgment.
Verbal format is useful when the case is complex, when several related questions share the same indicator set, or when a written template would be slower than a face-to-face review of the chart. It is a poor choice when you cannot capture the encounter, when the provider is rushing and likely to give a one-word answer you will later over-interpret, or when you are tempted to coach a diagnosis with your tone of voice. Leading is leading in the corridor too.
Trap: Calling a conversation "just education" because you did not open the query software. If you named the patient and asked for a reportable clarification, you queried. Record it.
Required documentation of the verbal encounter
The 2026 brief requires verbal queries and related conversations to be recorded with notation of all of the following:
- Element What to capture Why it matters
- Date and time When the conversation occurred Reconstructs the encounter for audit and discovery
- Individuals involved Who queried and who responded Identifies the responsible provider
Clinical indicators and source Findings plus where they live in the record Shows the question was evidence-based, not speculative
- Nonleading statement Why clarification is needed for this encounter Same job as the written query stem
- Answer options, if any Choices actually offered Options cannot be invented later in the tracker
- Provider's verbal response What was said, not what you hoped was meant The worksheet is not the diagnosis
Organizational policy decides where that notation lives and how others retrieve it. The compliance goal is that verbal queries are recorded and tracked in the same manner as written queries and are discoverable to other departments and external agencies. A secret sticky note in a CDI folder that nobody else can find is not a compliant verbal-query record.
Open-ended wording is often the cleanest way to document a verbal query: you list the indicators, you ask a nonleading question, and you record the provider's free-text spoken answer. If you offered multiple-choice options out loud, those options belong in the notation too. Do not silently drop the options you spoke and later type a narrower list that looks more billable.
The response must reach the permanent health record
This is the rule candidates invert. Logging the verbal encounter in the CDI database is necessary. It is not sufficient for code assignment. A response to a verbal query must be documented in the permanent health record before the clarified condition can be coded. The provider may write it in a progress note, the discharge summary, an addendum, or an approved query response that policy treats as part of the health record. Facility policy names the approved locations; the exam principle does not change with the software vendor.
If a compliant query has been properly answered and authenticated by a responsible provider and is part of the permanent health record, that response can support code assignment. It does not have to be recopied into a second note. If later documentation conflicts with the query response, you need another clarification—not a quiet decision to prefer the hallway version.
Trap: Coding from "the doctor told me" when the chart still lacks the diagnosis. Auditors, payers, and surveyors read the record, not your memory. ICD-10-CM assignment follows provider documentation in the health record, not an undocumented oral agreement.
When the provider says yes and never writes it
The 2026 brief is explicit about the failure path. If the verbal response is not documented in the permanent health record, the code supported by that response may not be assigned . The query professional should work with the provider to obtain written documentation through an addendum , or initiate a written query so the clarification travels through a documented channel.
Organizations should establish escalation processes for the familiar nightmare: the provider verbally agreed, then went to the operating room, signed out, or simply never returned to the note. Escalation is not harassment. It is the structured next step after a good-faith attempt to get the answer into the chart. If escalation is exhausted and the record still lacks the diagnosis, close the issue per policy and code what the record actually contains.
Do not "fix" the gap by entering the diagnosis yourself, by asking a different provider who never saw the patient to rubber-stamp the hallway answer, or by issuing the same leading question to every covering physician until someone types the preferred term. Those shortcuts convert a documentation delay into a compliance event.
Practical inpatient workflow
Use verbal queries when they genuinely help: a bedside review of conflicting notes, a quick POA question while the attending still remembers the ED course, or a complex case where walking through the labs together prevents a leading written template. Immediately afterward, enter the required notation. Confirm that the provider knows the answer must appear in the record. If the provider prefers to answer in writing, convert to a written query rather than leaving an oral maybe hanging.
Keep the spoken stem as disciplined as a template. Do not add "this would help our mortality index" as a persuasive closer. Do not offer only the diagnosis you want. Do not present indicators with your own diagnostic overlay ("so you agree this is severe malnutrition, right?"). Quote or cite the findings, ask the nonleading question, and stop talking long enough for the provider to answer.
Peer-to-peer discussions inside CDI and coding still need the same capture when they become encounter-specific queries. A coder asking a CDI specialist whether a guideline applies to an unnamed scenario is education. A coder asking a CDI specialist to get Dr. Patel to confirm encephalopathy on this death chart is a query process and must be documented accordingly.
Verbal speed helps only when the chart becomes clearer. An undocumented verbal yes is not a win. It is an open risk.