Q&A: “Unable to determine” and “other, please specify” as query choices
Q: Do we need to provide choices of "unable to determine" and "other, please specify" on our multiple-choice written queries? It was recommended that we use one or the other, citing the 2019 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice. These choices would be in addition to clinically relevant options related to the query topic.
A: The query brief does not necessitate a specific minimum amount of query choices for a multiple-choice query. However, it does state “additional options that permit the provider to craft their own alternate response” should be included (see p. 9 under the section titled “Written Queries”). Additionally, under the subsection title “Multiple choice,” the Guidelines state “There is no mandatory or minimum number of choices necessary to constitute a compliant multiple-choice query.”
“Multiple choice: Multiple choice query formats should include clinically significant and reasonable option(s) as supported by clinical indicator(s) in the health record, recognizing that occasionally there may be only one reasonable option. Providing a new diagnosis as an option in a multiple-choice list—as supported and substantiated by referenced clinical indicators from the health record—is not introducing new information. There is no mandatory or minimum number of choices necessary to constitute a compliant multiple-choice query.”
Including more than one alternative option is ultimately a decision of each organization’s CDI leadership team and/or compliance department.
The one choice that should be on all queries however, is “other.” You can state “other, please specify,” or just “other,” but there must be an alternate choice for the provider to be able to write out an answer of his or her own.
The point is that queries must offer an option for providers to document anything they feel is appropriate if he or she believes the choices provided on that multiple-choice query do not apply to condition(s) being treated for that patient during that encounter.
Also, queries should be customized to each case, so there’s nothing wrong with adding “other, please specify” and “clinically unable to determine” on the same query. It will all depend on the premise of the query.
Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.