Q&A: Yes/no query for post-op hematoma

Q: The provider linked a post-op CT finding of “probable hematoma” in their documentation. Per the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief, a “yes or no” query can be sent to confirm radiology findings. Additionally, this is an uncertain diagnosis, but it is listed on the discharge summary. 

Can a “yes/no” query be sent based on this documentation (Yes, there is a post-op hematoma or No, there is not a postop hematoma, other)? Or would this be seen as introducing a new diagnosis and thus non-compliant?

A: As we know, providers will often pull diagnostic information from the medical record into their notes or documentation. This is usually a function within many types of EHR software. We also may see this performed as a copy-and-paste process. In either situation, the provider is expected to review this information prior to final signature on the documentation, making it reportable unless stated otherwise. 

A condition being stated in a radiology study that is not “correlated” directly by the provider in documentation makes it questionable, especially when stated as probable. As we know per the Official Guideline for Coding and Reporting, an inpatient condition documented as possible, probable, likely, or some other uncertain term can be reported if documented at the time of discharge as long as there is diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. If the condition meets these criteria, then it is reportable and would not need to be queried. Your example is one that we often struggle with. While it may be reportable, we question whether it is valid.

In consideration of a query, we look to the query practice brief, which can assist in answering two questions: Is it appropriate to query, and what is the appropriate type of query?

According to the brief, you would query to determine if a diagnosis is ruled in or out. You can utilize many types of queries in this situation, including a “yes/no” query, however, the “yes/no” query may not be your best choice. According to the practice brief, a “yes/no” query may be applicable when “substantiating a diagnosis that is already present in the current health record (e.g., findings in pathology, radiology, other diagnostic reports) with interpretation by a provider in the inpatient setting.” 

While a “yes/no” query can be utilized, our role as CDI specialists is to assist the provider to document with high specificity and accuracy by providing relevant clinical information to make an informed decision. In this case, it would be more supportive to utilize a clinical validation query, example #1, option 2 in appendix A of the brief. I have revised the example to your situation.

Probable hematoma was documented on CT report dated xx/xx and your note dated xx/xx.

Please clarify the diagnosis of probable hematoma:

• Probable hematoma ruled out
• Probable hematoma confirmed (please document additional supporting information or mitigating factors)
• Other explanation of clinical findings (please specify) __________

To strengthen this query, include any additional clinical indicators that are present or not present, such as:

• Any injury or surgery of the patient that could cause a hematoma
• The site of the hematoma
• Any secondary insult/complication the patient is having from the hematoma (e.g., acute blood loss anemia, pain, inflammation, swelling, return to operating room)

The goal is to efficiently and effectively achieve the result of a condition that is clinically valid, supported, specific, and accurate. If we were to utilize a “yes/no” query in this instance, we leave it open to question on each of these factors. 

Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at dwilk@hcpro.com.