Query Tip: Be Careful Using Yes/No Query Format
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.
- Present on admission determination
- 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)
- Establishing a cause and effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings
- 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.
Popular Posts
Coding Tip: New ICD-10-CM General Coding Guideline — Coding for Healthcare Encounters in Hurricane Aftermath
With the Hurricane season in full swing, this new guideline will be helpful in reporting the external cause codes when an injury occurs as a result of the hurricane, and also help in determining sequencing of the reported codes.
Coding & Quality Measures Tip: Coding for the Revised Stroke Mortality Measure (MORT-30-STK)
The refined Stroke 30-day mortality measure (MORT-30-STK) is a statistic defined as death occurring within 30 days of a diagnosed stroke. The Centers for Medicare & Medicaid Services (CMS) publicly reports a 30-day hospital-level stroke mortality measure on Hospital Compare as part of the Inpatient Quality Reporting (IQR) program.
Coding Tip: Coding Lobar Pneumonia
“Lobar” pneumonia references a form of pneumonia that affects a specific lobe or lobes of the lung. This is a bacterial pneumonia and is most commonly community acquired. Antibiotics are almost always necessary to clear this type of pneumonia.
Coding Tip: What is Hydronephrosis?
We have seen a lot of recommendations of late where the coders are coding hydronephrosis, UTI and ureteral stone separately or not with the correct code to include all conditions.
Coding Tip: Cerebral Infarction When Patient Has Carotid Stenosis
Coders have struggled for some time with the dilemma of when to assign the combination code of carotid stenosis, with cerebral infarction (i.e.I63.231) and when to assign separate codes for the specific cerebral infarction and carotid stenosis. (i.e. I66.01 and I65.21).
Subscribe to our weekly newsletter
Latest News
Coding Tip: New ICD-10-CM General Coding Guideline — Coding for Healthcare Encounters in Hurricane Aftermath
With the Hurricane season in full swing, this new guideline will be helpful in reporting the external cause codes when an injury occurs as a result of the hurricane, and also help in determining sequencing of the reported codes.
Coding & Quality Measures Tip: Coding for the Revised Stroke Mortality Measure (MORT-30-STK)
The refined Stroke 30-day mortality measure (MORT-30-STK) is a statistic defined as death occurring within 30 days of a diagnosed stroke. The Centers for Medicare & Medicaid Services (CMS) publicly reports a 30-day hospital-level stroke mortality measure on Hospital Compare as part of the Inpatient Quality Reporting (IQR) program.
Coding Tip: Coding Lobar Pneumonia
“Lobar” pneumonia references a form of pneumonia that affects a specific lobe or lobes of the lung. This is a bacterial pneumonia and is most commonly community acquired. Antibiotics are almost always necessary to clear this type of pneumonia.
Coding Tip: What is Hydronephrosis?
We have seen a lot of recommendations of late where the coders are coding hydronephrosis, UTI and ureteral stone separately or not with the correct code to include all conditions.
Coding Tip: Cerebral Infarction When Patient Has Carotid Stenosis
Coders have struggled for some time with the dilemma of when to assign the combination code of carotid stenosis, with cerebral infarction (i.e.I63.231) and when to assign separate codes for the specific cerebral infarction and carotid stenosis. (i.e. I66.01 and I65.21).
Query Tip: The Many Meanings of “Unable to Determine”
Queries written in a multiple-choice format include a short list of options for physician response. These options must be relevant and supported by the clinical indicators included in the query.
Coding Tip: Getting Control of Root Operation Control
Since the implementation of ICD-10-PCS in 2015, yearly changes have been made regarding the definition of, and guidelines associated with, the root operation Control. This has caused coding professionals much confusion in determining whether to assign a procedure to root operation Control, to assign another root operation, or to not assign a procedure code at all.
IPPS Final Rule: Here’s What You Need to Know
The policies in the IPPS/LTCH PPS final rule further advance the agency’s priority of creating a patient-centered healthcare system by achieving greater price transparency, interoperability, and significant burden reduction so that hospitals can operate with better…
Coding & Quality Measures: The Code Hard Truth
In this current, ever-changing healthcare climate, health systems face many challenges. Facilities large and small must be dedicated to improving documentation and reducing complications, HACs, infection rates, and readmissions as they endeavor towards value-based care. Coding inaccuracies can really undermine…
Achieve Sustained Results with HIA’s Coding Services
It’s imperative, in today’s challenging healthcare environment, that organizations demand complete and accurate coding practices from their vendors if they want: Appropriate and timely reimbursement; Representative quality measures; Improved CMI; Reduction in payor denials and; Mitigation of compliance risks.
Query Tip: Is Sepsis Present on Admission?
In addition to positive clinical indicators documented at the time of admission, any of these that occur within the few days after admission should also be included. This will support the fact that sepsis could have developed after admission. It is important that a POA query give equal attention to what supports POA yes, as well as POA no to avoid the appearance of a leading query.
CMS Releases Proposed Physician Fee Schedule Rule for CY 2019
This major proposed rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.
Want a sneak peek at ICD-11?
For example, open the ICD-11 online link and click on “Browse the release version.” Then choose “Coding Tool” tab at the top. We chose “sepsis.” Sepsis without shock is coded to 1G40. Sepsis with septic shock is coded 1G41. A bit different than ICD-10!
Coding & Quality Measures Tip PQI 07: Hypertension Admission Rate
Did you know that by coding hypertension with associated CKD correctly along with any surgical dialysis access creation on patients admitted with hypertension, will keep the case out of the AHRQ PQI #07: Hypertension Admission Rate quality measure?
ICD-11: 3 Key Takeaways
On June 18, 2018, the World Health Organization (WHO) released a preview of its new International Classification of Diseases (ICD-11). ICD-11 will be formally presented at the World Health Assembly on May 2019 for adoption by Member States, and will come into effect the 1st of January 2022. The advanced preview will allow countries to plan how to use the new version to prepare translations and train health professionals.
Coding Tip: Reporting Intra-Aortic Balloon Pump (IABP) in ICD-10-PCS
From a coding perspective, the IABP is not classified as a device such as the VAD’s. The IABP is not coded as a device within ICD-10-PCS and is coded with the root operation of “Assistance.” The ICD-10-PCS code for insertion of an IABP for continuous pumping would be 5A02210, Extracorporeal or Systemic Assistance, Physiologic Systems, Assistance, Cardiac, Continuous, Output, Balloon Pump.
Query Tip: Query Question is Key
The key to a quality physician query is the question. The question provides direction for the choice of clinical indicators and options for response. So why do so many coders have trouble writing the question? My theory is that coders overthink the question rather than keeping it simple and to the point. The best way to get a physician to answer a query is with a question that makes sense and eliminates guessing as to what is being asked.
Q1 2018: Top 5 Procedure Code Changes
Locating ventilator times were difficult in the paper medical record, but has not become any easier with the implementation on the electronic health record (EHR.) Coders should be encouraged to review the record for exact ventilator times. As mentioned above, this could come down to minutes when selecting the correct ICD-10-PCS code.
Who Tells Your Story?
Hamilton. If you haven’t seen it, you’ve heard of it. The Broadway mega-hit has been the toughest ticket on Broadway since its debut in 2015. For the uninitiated, Hamilton explores the life and triumphs of the previously obscure “ten-dollar founding father,” Alexander Hamilton, through rap, hip-hop, and musical theatre.
Coding Tip: Excisional Debridement Coding to the Furthest Layer
Procedure code assignment for excisional debridement has always been a focus area in coding audits. The biggest concern is whether or not the debridement is truly excisional in nature, and if the documentation truly supports an excisional debridement. HIA has written a previous Coding Tip on determining nonexcisional vs excisional debridement.
Query Tip: Bullet vs Paragraph: What Format is Best for Clinical Indicators?
Beth Martilik, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador The ultimate goal of a physician query is to obtain clarity to physician documentation in the patient’s health record. In order to accomplish this goal,...
Coding Tip: New Technology Drugs FY 2018
Kim Carrier RHIT, CDIP, CCS, CCS-P Director of Coding Quality Assurance AHIMA Approved ICD-10-CM/PCS Trainer New Technology-ICD-10-PCS Section “X” DRUGS Section “X” is a separate place within ICD-10-PCS for certain new technology procedures (such as new technology...
Query Tip: Avoiding a Leading Query – Introduction of a New Diagnosis
Beth Martilik, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador “A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or...
Coding Tip: Bronchoscopy with Removal of Mucus Plugs or Foreign Body
Pat Maccariella‑Hafey, RHIA, CDIP, CCS, CCS‑P, CIRCC Executive Director Of Education AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador Bronchoscopy with Removal of Mucus Plugs or Foreign Body HIA has previously discussed the coding of bronchoscopy with...
Query Tip: The Importance of Queries
Most queries are written to clarify documentation as it relates to reimbursement. However, code assignment not only impacts reimbursement, but also other significant uses of coded data. Ideally, queries would be written as necessary to ensure data integrity and full and complete documentation.
Coding Tip: Inpatient Coding of Probable Diagnoses
The rules about coding probable, possible and questionable diagnoses did not change with the implementation of ICD-10-CM. A possible, probable, suspected, likely, questionable, or still to be ruled out condition can be coded if still documented as such at the time of discharge.
6 Benefits of an External Audit
Many organizations routinely perform internal audits as part of a compliance plan. Internal auditors have an insider’s view of the work flow of the organization. Unfortunately, they are auditing their coworkers, friends or employers.
CMS Changes the Rules on Student Documentation
Anyone who has coded or reviewed documentation in a teaching facility is familiar with the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1. This section of the manual contains the guidelines for teaching physicians.
Coding Tip: Chronic Kidney Disease Coding
Kim Carrier RHIT, CDIP, CCS, CCS-P Director of Coding Quality Assurance AHIMA Approved ICD-10-CM/PCS Trainer Chronic kidney disease (CKD) is the gradual loss of kidney function. The function of your kidney is to filter waste and excess fluids from your blood and...