Query Tip: Be Careful Using Yes/No Query Format

by | Sep 20, 2018 | Beth Martilik, Education, Query Tip | 0 comments

Beth Martilik​, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador Beth Martilik,​ MA, RHIA, CDIP, CCS
Assistant Director of Education
AHIMA Approved ICD‑10 Trainer and Ambassador

Until recent years queries were not designed for questions that could be responded to in a yes/no fashion. Open-ended or multiple choice formats were generally accepted. In a February 2013 Practice Brief (updated 2016) titled “Guidelines for Achieving a Compliant Query Process,” AHIMA introduced the Yes/No query format.

Queries in a Yes/No format are limited to use in the four specific circumstances listed below. This format may not be used when only clinical indicators of a condition are present, but the diagnosis has not been documented in the health record.

  1. Present on admission determination
  2. Substantiating or further specifying a diagnosis that is already present in the health record with interpretation by a physician (i.e. findings in pathology, radiology, and other diagnostic report)
  3. Establishing a cause and effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings
  4. Resolving conflicting documentation from multiple practitioners

Yes/No queries would still contain clinical indicators that support the question being asked.  The difference between this format and others commonly used would be in how the question is asked and the options listed for physician response.

Example 1

The physician gives a final diagnosis of abdominal mass, but the pathology report indicates a finding of adenocarcinoma of the sigmoid colon. A query is necessary to confirm the etiology of the mass. 

Question:  Do you agree with the pathology report that the etiology of the abdominal mass is adenocarcinoma of the sigmoid colon?

Options for response:

  • Yes
  • No
  • Other
  • Unable to determine

Example 2

Patient develops an abscess at the incision site of a recent hysterectomy. A query is necessary to establish a cause and effect relationship between the abscess and surgery.

Question: Is the abscess a complication related to the recent hysterectomy?

Options for response:

  • Yes
  • No
  • Other
  • Unable to determine

A limitation of the Yes/No query format is that it may leave the physician response open to interpretation. By not having the response specifically spelled out, the coder will have to carefully design the question to avoid misinterpretation. All it takes is a question that is not specific enough to make the response questionable and may lead to the need to requery for clarification.

Example 3

The surgeon creates several serosal tears of the bowel during a tedious lysis of adhesions. These are repaired with simple sutures.  A query is necessary to establish a cause and effect relationship that may represent a complication.

Question:  Are the serosal tears of the bowel related to the lysis of adhesions?

Response:  Yes

With this question and response, the coder is left wondering if the serosal tears are a true complication of the surgery, or an incidental occurrence that would not be coded as a complication. It may be advisable in this situation to use a multiple choice format to differentiate between complication versus no complication. Another option is to reword the question: “Are the serosal tears considered a clinically significant complication of the lysis of adhesions?”

Coders will have to be careful in the use of the Yes/No query format and to make sure it is only used in the specified scenarios. It is up to the coder to determine which format – open ended, multiple choice or Yes/No fits his/her needs and preferences. Each format has limitations, but give the coder options to achieve the goal of complete and accurate documentation in the health record.

As with any query, the physician response needs to be included in the medical record. This may be in the form of the actual query form or as written documentation in the record.

 

The information contained in this query advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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