Q&A: Singular diagnosis option may not be leading

Q: Can you please provide me any additional information that supports the option of only offering a single possible diagnosis on a query form? We are working to simplify our query system but are having some difficult discussions regarding whether offering a single diagnosis is “leading” or not.

A: The ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” published last year states (emphasis added):

• A leading query is one that is not supported by clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. Justification (i.e. inclusion of relevant indicators) for the query is more important than the query format.
• Multiple choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record recognizing that there may only be one reasonable option.

The recommendations tell us to offer any/all reasonable options, “other,” and “unable to determine,” as choices. The key words are “any reasonable options.”

There are times when the clinical indicators specific to the patient only lead to one reasonable option. In those cases—if there is no other diagnosis that could be explained by the clinical indicators—you only need to offer that diagnosis accompanied by the choices of “other” and “unable to determine.”

You do not want to add diagnoses that cannot be explained by the patient’s presentation (clinical indicators) for the singular purpose of adding more choices to meet previous query guidelines.

When I first learned to write multiple choice queries, I was taught to include the two choices of other and unable to determine and then add choices that would affect reimbursement and choices that would not. The thought behind that early practice was that such queries would be deemed more compliant, more non-leading, if CDI specialists offered a variety of choices.

Yet, this practice forced us to add choices that may not have been clinically valid to the patient’s current condition just to fill in a blank choice.

According to the definition of “leading” in the latest query practice guidance written above, if we are offering choices that are not appropriate to the patient’s presenting clinical indicators, we are writing a leading query. That is why CDI specialists should only offer choices which accurately reflect the patient’s clinical indicators and there may be times when only one choice is appropriate.

Review the query practice brief and highlight those quotes that speak to leading and non-leading queries and the development of multiple choice queries. I think this is a great exercise to standardize practices between the coding and CDI staff within your organization. This might open the door to some interesting dialogue and changes within your organization.

Editor’s Note: CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview. This article was originally published on the ACDIS Blog.