Are Leading Queries Prohibited by Law or Lore?

by  Erica E. Remer, MD CCDS
Oct 13th, 2022

AHIMA released its CDI Practice Brief Monday.

At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag.

Halacha is law; it is the prescriptions and proscriptions set in the Bible and other rabbinic legislation. Thou shalt not murder; Honor thy father and mother; rules for celebrating post-Biblical holidays. Minhag is tradition or custom, and, although the practices may have become so commonplace as to be near universal, they are not derived from law, per se. Wearing a head covering (i.e., a yarmulke or kippah) in the synagogue and avoiding rice, lentils, and legumes at Passover in the Ashkenazi tradition are examples of minhagim (the plural of minhag).

The question that was posed by a listener of Monitor Mondays was, “Does the law prohibit leading questions in queries?” and they asked for a source. There was no time to answer on air, and Ron (Dr. Ronald Hirsch, MD) kicked the football to me. Behind the scenes, healthcare attorneys David Glaser and Knicole Emanuel both concurred that there is no law, rule, or regulation prohibiting leading queries, and I agree. However, there is more to this.

One of the hardest things I had to do as a physician advisor was wrap my head around the term, “compliance.” I finally settled on it indicating going along with the rules, which to me implied the government’s rules, regulations, and laws. However, in addition to external requirements, compliance can reflect following your organization’s internal rules, policies and procedures, and acting in accordance with ethical practices. Laws, rules, and regulations are halacha; industry standards and organization’s internal rules, policies and procedures are minhag.

What is a leading query? It is a request for clarification that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. If it is not supported by the clinical indicators, then it will not be a valid condition, even if documented in the record.

Attempting to guide the provider into desired documentation for reimbursement or quality reasons is also noncompliant. Only the clinician caring for the patient is qualified to make diagnoses; clnical documentation integrity specialists (CDISs) must not overreach.

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This article originally published on October 10, 2022 by ICD10monitor.

About Erica E. Remer, MD CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.