Q&A: Escalating “Unable to determine” query responses

Q: What actions do CDI teams take when staff receive “unable to clinically determine” responses to queries? Some physicians may use this as an easy query “out” versus addressing the clinical question and we are seeing some repeat offenders. We started tracking and presenting these to our physician champions for further physician education. My question is whether others have additional advice? Do you word your queries differently to address this? For example, do you add “Clinically unable to determine (please remember it is acceptable to diagnose a condition as possible, probably, likely, suspected)?”

A: At Brigham and Women’s Hospital in Boston, CDI Director Deb Jones, RN, MSN, CCDS, developed a policy to escalate any “unable to determine” responses from low-level (resident or physician assistants) clinicians and found a reduction in those types of responses just by having the policy in place. Any higher-level clinician with a pattern of “unable to determine” responses are referred to the service line chiefs.

At the University of Texas Southwestern Hospitals, CDI Manager Kathryn Welch, MSN, RN, CCM, CCDS, says their program had a “big problem with physicians answering ‘unable to determine’ in order to make the query go away.” So, they educated the physicians and discussed an escalation process but ended up moving in a different direction. Instead, they removed “unable to determine” from their query options and left the “other” option and saw a dramatic improvement in response rate.

The 2008 query practice recommendation from the AHIMA indicated that providers should be given an "unable to determine" choice, noted Shawn MacPhee, MSN, RN, CCDS, CDIP, Regional CDI Director at McLaren Health Care Corporation in Flint, Michigan. The 2019 joint ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice states that, "Multiple choice query formats should also include aditional options such as 'clinically undetermined' and 'other' that would allow the provider to add free text. Additional options such as 'not clinically significant' and 'integral to' may be included on the query form if appropriate."

Only the provider can diagnosis the patient so queries need to include space for the provider to share his or her clinical perspective in order to maintain compliance.

Editor’s note: This question and answer were shared as part of the ACDIS Leadership Exchange.  The Leadership Exchange is a special, limited engagement exchange of ideas focused on management of CDI programs.