The medical record is a clinical tool used to share valuable information with other healthcare professionals within the same and other healthcare facilities. The priority of providers when entering notes is continuity of care, not creating an invoice to support a bill, yet that is what payers have come to expect.
One of the most egregious examples of self-inflicted revenue leakage at hospitals is when leadership within the clinical revenue cycle departments (e.g., clinical documentation integrity/CDI and coding) allow payer expectations to drive organizational practices. Querying the provider to add all diagnoses classified as a complication/comorbidity (CC) or major CC (MCC) to the discharge summary is one such type of process.
A related myth is that a diagnosis must appear consistently throughout the medical record. These beliefs have driven countless late-stage queries, frustrated providers, and fueled payer denials.
While it may feel like a longstanding rule, this is not, and never has been, a requirement under authoritative coding guidance. Historically, when only one provider cared for a patient, the discharge summary functioned as the definitive diagnostic statement for the hospitalization.
This expectation evolved into a belief that if a diagnosis was not restated in the discharge summary, it was somehow incomplete, unimportant, or invalid for coding. Yet, this is not a requirement of ICD-10-CM Official Guidelines for Coding and Reporting.
In fact, the Official Coding Guidelines and Coding Clinic have long instructed coders to review the entire medical record when assigning codes, not just the discharge summary. The discharge summary has always been a valuable clinical document and an important communication tool, but it has never been the sole source of truth for code assignment. Nonetheless, payer reviews often begin with the discharge summary, and when a diagnosis does not appear there, it is frequently challenged. I
n response, CDI and coding professionals conceded by issuing queries solely to have diagnoses “carried forward” into the discharge summary, even when those diagnoses were already clinically supported and documented elsewhere in the record, in hopes of preventing a bogus denial.
This practice is inefficient and counterproductive. Queries issued only to restate an already valid diagnosis add little clinical value, consume limited CDI resources, and annoy providers who believe – often correctly – that they have already documented the condition. More importantly, these queries reinforce the very myth that payers later exploit in denials.
Current authoritative guidance clearly contradicts this belief. The ICD‑10‑CM Official Guidelines state that code assignment is based on provider documentation and that the entire record must be reviewed to determine reportable diagnoses.
Coding Clinic has repeatedly clarified that documentation is not limited to any single note type, including the discharge summary. A diagnosis documented by a responsible provider anywhere in the record may be coded, provided that it meets reporting criteria and is not contradicted by other documentation.
The draft 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice dismantles this myth by offering long‑overdue clarity that should reshape how CDI and coding professionals approach both querying and appeals. It explicitly states that if a compliant query has been properly answered, authenticated, and made part of the permanent health record, it is sufficient for code assignment.
It does not need to be repeated elsewhere in the record. Just as importantly, the brief states that there is no specific direction as to where a diagnosis must be documented or how often it must be documented in order to be reported.
This language is significant. It balances the importance of clinical indicators with clinical documentation. Remember, the purpose of querying is to add ICD-10-CM terminology into the health record to allow non-clinicians to report clinically significant diagnoses on a claim. The frequency with which that terminology is used throughout the chart is irrelevant.
The diagnostic label may appear only once, including within a compliant query response, and still be valid for coding.
This clarification is especially relevant given how query practices have evolved. When querying was first introduced, open‑ended queries were the norm, and query responses were not automatically part of the permanent medical record. Providers had to document their response in a subsequent note, which often meant adding it to the discharge summary. CDI specialists spent considerable time chasing that follow‑up documentation.
As electronic health records (EHRs) matured, query forms themselves became part of the legal medical record. Multiple‑choice queries emerged as a more efficient and effective approach, offering providers clinically appropriate options aligned with coding terminology. This shift improved clarity, reduced ambiguity, and eliminated the need for redundant documentation. Despite this evolution, many organizations continued to operate as though the older rules still applied, requiring diagnoses clarified through queries to be restated in progress notes or discharge summaries.
The draft practice brief explicitly rejects that requirement. A compliant query response is provider documentation. It carries the same weight as any other authenticated note in the record, and does not require repetition to be valid.
This guidance should be incorporated directly into appeal strategies. When a payer challenges a diagnosis based on frequency or location of documentation, CDI and coding professionals can now point to industry consensus stating that no such requirement exists.
The focus should be returned to whether the diagnosis is clinically supported and meets reporting criteria, not whether it appears multiple times, or within a particular note.
This does not mean that the discharge summary is unimportant. It remains a best practice for providers to summarize all clinically significant diagnoses addressed during the admission, both for continuity of care and for clarity. Encouraging complete discharge summaries is appropriate, from a clinical and quality perspective. What must change is the belief that omission from the discharge summary invalidates a diagnosis that is otherwise well-supported.
Unnecessary queries do not improve documentation integrity. The draft 2026 Query Practice Brief offers clarity that allows CDI professionals to refocus their efforts on meaningful clinical clarification, rather than cosmetic documentation fixes. A clinically significant diagnosis, documented once by a provider, that meets reporting requirements, is enough.
It does not need to be chased, duplicated, or defended simply because it appears only once or does not appear in the discharge summary.
Letting go of these myths allows CDI and coding professionals to practice more efficiently, support providers more effectively, and push back confidently against flawed denial rationales that have lingered far too long.
