Provider Query Templates for Risk Adjustment Coders (Compliant Examples)

A provider query is a written question from a coder or CDI specialist to a treating provider asking for clarification, additional specificity, or confirmation of a diagnosis. Done correctly, queries are one of the highest-leverage tools a risk adjustment coding team has — they recover RAF that would otherwise be lost to vague documentation. Done incorrectly, they create compliance risk and can be cited as evidence of upcoding in a RADV audit or False Claims Act investigation.

This guide provides compliant query templates for the most common HCC documentation gaps, based on the AHIMA / ACDIS practice brief on guidelines for achieving a compliant query practice. Every template here follows the four AHIMA rules: open-ended (or a multiple-choice format with a "none of the above / cannot be determined" option), based on documentation already in the chart, free of leading language, and providing clinical indicators.

What Makes a Query Compliant

The AHIMA / ACDIS practice brief is the industry standard, and most plan compliance programs require coders to follow it. The four core rules:

1. The query must be supported by clinical indicators in the chart. You cannot ask a provider to add a diagnosis that has no clinical evidence. The query template should reference the specific labs, vitals, medications, or symptoms that prompted the question.

2. The query must not lead the provider toward a specific answer. "The patient has CHF, correct?" is leading. "Based on the EF of 25% and the prescription for furosemide and metoprolol, can you clarify the type of heart failure?" is not.

3. Multiple-choice queries must include a 'none of the above' or 'cannot be determined' option. A query that only offers diagnoses you want the provider to pick from is not a query — it is a coding suggestion, and it fails compliance review.

4. The query must not include the financial impact. Mentioning the RAF, the HCC weight, or the dollars at stake is an automatic compliance failure. The provider must answer based on clinical judgment, not on revenue.

Template 1 — Diabetes With Complications

When to use: Chart shows diabetes plus a related condition (CKD, neuropathy, retinopathy, vascular disease) but the provider has not explicitly linked the two with a combination code.

Clinical indicators in the chart: Document the specific evidence — for example, "eGFR 42, urine albumin/creatinine 380 mg/g, type 2 diabetes documented in the assessment."

Query language:

> Dr. [Name],

>

> The chart for [Patient Initial], DOS [date], documents type 2 diabetes mellitus. The same encounter notes an eGFR of 42 and a urine albumin/creatinine ratio of 380 mg/g, which are clinical indicators of chronic kidney disease.

>

> Could you please clarify the relationship between these two conditions, if any?

>

> - Diabetic chronic kidney disease (please specify CKD stage)

> - Chronic kidney disease unrelated to diabetes

> - Other (please specify)

> - Cannot be determined / clinical relationship not yet established

What this captures. If the provider answers "diabetic CKD stage 3a," the coder can submit E11.22 + N18.31, which maps to HCC 36 (Diabetes with Severe Acute Complications) or HCC 37 (Diabetes with Chronic Complications) in V28 depending on the specific complication, instead of just E11.9 + N18.31, which under V28 captures only the CKD HCC and loses the diabetes HCC entirely.

Template 2 — Heart Failure Type and Acuity

When to use: Chart says "CHF" or "heart failure" without specifying systolic vs. diastolic, with or without preserved ejection fraction, and without specifying acute, chronic, or acute on chronic.

Clinical indicators: Most recent echocardiogram with EF, current medications, and any hospitalization for heart failure in the past 12 months.

Query language:

> Dr. [Name],

>

> The chart for [Patient Initial], DOS [date], documents "CHF." The most recent echocardiogram on [date] showed an ejection fraction of [value]. Current medications include [list].

>

> To support accurate coding, could you please clarify the type and acuity of the heart failure?

>

> Type:

> - Systolic (HFrEF)

> - Diastolic (HFpEF)

> - Combined systolic and diastolic

> - Other (please specify)

> - Cannot be determined

>

> Acuity at the time of this visit:

> - Acute

> - Chronic

> - Acute on chronic

> - Compensated / stable

> - Cannot be determined

What this captures. Heart failure is one of the highest-RAF HCCs in V28 (HCC 226 — Heart Failure). The unspecified code I50.9 maps to no HCC in V28, while specified codes like I50.22 (Chronic systolic CHF) map to HCC 226 with a meaningful weight.

Template 3 — Depression Severity

When to use: Chart says "depression" or "MDD" without specifying severity. Common in primary care notes.

Clinical indicators: PHQ-9 score, current medications, any history of inpatient psychiatric care or suicidal ideation.

Query language:

> Dr. [Name],

>

> The chart for [Patient Initial], DOS [date], documents "depression." The most recent PHQ-9 score was [value], and the patient is currently taking [medication].

>

> To support accurate coding under ICD-10-CM, could you please clarify the severity of the depressive disorder at the time of this visit?

>

> - Mild

> - Moderate

> - Severe without psychotic features

> - Severe with psychotic features

> - In partial remission

> - In full remission

> - Other / not depression — please clarify

> - Cannot be determined

What this captures. Under V28, F32.9 and F33.9 (unspecified severity) do not map to any HCC. Specified severity codes like F32.1 (Moderate single episode) or F33.1 (Moderate recurrent) do map to an HCC. This single query template, deployed consistently, recovers meaningful RAF in primary-care heavy plans.

Template 4 — Cancer: Active vs. History

When to use: Chart references a malignancy but it is unclear whether the patient is currently being treated or whether the cancer is in remission and being followed only.

Clinical indicators: Date of original diagnosis, most recent oncology note, current treatment status, surveillance imaging results.

Query language:

> Dr. [Name],

>

> The chart for [Patient Initial], DOS [date], references [type of cancer], originally diagnosed [date]. The patient is followed by oncology and is currently on [treatment, or "surveillance only"].

>

> To support accurate coding, could you please clarify the current status of the malignancy?

>

> - Active malignancy, currently receiving primary or adjuvant therapy

> - Active malignancy, no current treatment

> - Personal history of malignancy, no evidence of disease, surveillance only

> - Recurrent or metastatic disease (please specify site)

> - Cannot be determined

What this captures. Active malignancy codes (C-codes) map to HCCs under V28; personal history codes (Z85.x) do not. A patient on surveillance with no evidence of disease should be coded Z85.x, not as an active C-code — this is one of the most common RADV failures and one of the most common audit recoveries against plans.

Template 5 — Vascular Disease Specificity

When to use: Chart says "PVD" or "atherosclerosis" without specifying the affected vessel and the symptom (claudication, rest pain, ulceration, gangrene).

Clinical indicators: ABI results, vascular imaging, exam findings, symptom description.

Query language:

> Dr. [Name],

>

> The chart for [Patient Initial], DOS [date], documents "peripheral vascular disease." The exam noted [findings] and the most recent ABI was [value].

>

> To support accurate coding, could you please clarify the location and the clinical findings?

>

> Affected vessel:

> - Right leg

> - Left leg

> - Bilateral lower extremities

> - Other (please specify)

>

> Clinical findings at this visit:

> - Asymptomatic atherosclerosis

> - Intermittent claudication

> - Rest pain

> - Ulceration (please specify location)

> - Gangrene

> - Cannot be determined

What this captures. Under V28, unspecified atherosclerosis codes lose HCC mapping. Specified vessel + symptom codes (the I70.2x family) map to HCC 263 — Atherosclerosis of the Extremities with Ulceration or Gangrene, or related vascular HCCs depending on the specific finding.

Leading-Question Patterns to Avoid

These are the patterns that fail compliance review and create RADV exposure:

Avoid: "The patient has diabetic CKD, correct?" This is leading. The provider has not been asked to evaluate the clinical relationship — they have been told what to write.

Avoid: "Please add diabetic CKD to the assessment." This is a coding instruction, not a query. The provider has no opportunity to disagree or to specify a different relationship.

Avoid: "Coding this encounter requires a specified depression code. Please choose mild, moderate, or severe." The phrase "coding this encounter requires" introduces a financial pressure into the clinical decision, even without naming dollars. Restate as a clinical clarification request.

Avoid: "The HCC weight for this diagnosis is X — can you confirm it?" Mentioning HCC weights or RAF in any form is an automatic failure on compliance review and can be cited in a RADV audit as evidence of inappropriate coder influence on documentation.

How to Track and Audit Your Query Program

Every query should be logged with:

Plans with mature CDI programs run quarterly internal audits of a 5–10% sample of queries to check for leading language, missing 'none of the above' options, and queries that did not have clinical indicators. Catching these before they show up in a RADV chart submission is much cheaper than appealing them after the fact.

A compliant query program is one of the highest-ROI investments a risk adjustment coding team can make. The templates above will not capture every gap, but they cover roughly 70% of the V28 documentation issues most plans see, and they are the right place to start.