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
2. Substantiating or further specifying “a diagnosis that is already present in the record”
Is this patient’s diabetes insulin dependent? Yes/No
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
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
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.
Dealing With Legibility Issues And Challenging Handwriting?
- 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
Attn: CDI specialists! Libman Education’s ICD-10 Documentation Quick Reference Guide is the one reference you need to help your physicians get it right. Help ensure your documentation provides sufficient detail to allow complete and accurate coding. Learn more here.