Appropriate Use Of Yes/No Physician Queries

Appropriate Use Of Yes/No Physician Queries


by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.

Specific instances where Yes/No queries are acceptable

In general, queries should not be designed to ask questions that result in a Yes/No response.  Like everything in life, there are exceptions.

1. Exception: POA queries when a diagnosis has already been documented.

Was the pressure ulcer POA?  Yes/No
OTHER/COMMENT________________

2. Substantiating or further specifying “a diagnosis that is already present in the record”

Is this patient’s diabetes insulin dependent?  Yes/No
OTHER/COMMENT______­­­­­__________

3. Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications and conditions/diagnostic findings

Is there a cause and effect relationship between the patient hypertension and their heart failure?  Yes/No
OTHER/COMMENT________________

4. To resolve conflicting practitioner documentation

A consultant states the patient’s BMI is 30 but the dietician states it is 41.7.
Is the dietician’s calculation correct?  Yes/No
OTHER/COMMENT_________________

Anytime you are presenting a physician with a Yes/No type query, always offer an “other” option for uncertain/unclear and to create a space for the physician to leave a comment.

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Dealing With Legibility Issues And Challenging Handwriting?


References:

  • AHIMA Practice Brief: Managing an Effective Query Process, 2008
  • AHIMA Practice Brief: Ensuring Legibility of Patient Records, 2003
  • AHIMA Practice Brief: Guidance for Clinical Documentation Improvement Programs, 2010

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About the Author

Chris Richards, RHIA, CCS
Chris joined Barry Libman Inc. as a Senior Associate in 2014 after 27 years with Masspro, the Massachusetts Quality Improvement Organization (QIO). Chris’s areas of expertise include health information administration, case management, quality improvement, hospital payment oversight, and documentation education initiatives. He has a comprehensive understanding of the Federal Medicare program rules and regulations, as well as extensive experience ensuring that clinical coding and DRG assignment result in accurate provider reimbursement. A graduate of Hobart College, he received a postgraduate Bachelor of Science in Health Information Administration from Northeastern University.

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