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October 30, 2022

Clarification on a discharge diagnosis of malnutrition.

The CDI team requested clarification on a discharge diagnosis of malnutrition. The providerwrote his response directly on the query form but did not sign or date the response. Therewas an amendment to the patient’s medical record. Upon receipt of the handwritten queryresponse, the coding staff proceeded to code and finalized the chart for billing. The queryform is scanned and retained in an electronic folder in the EHR. Query: 1. Indicate if this is a compliant query process—why or why not? If not, state what isrequired to document and retain a query response

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