Health Information Management

Q&A: Use yes/no queries to resolve surgical complication questions

CDI Strategies, January 16, 2014

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Q: We are struggling with how to query physicians regarding complications of procedures or surgeries. For example, a patient was readmitted for a bile leak two weeks after a cholecystectomy. Neither the attending nor the GI consultant ever stated that this was a complication. Can you give me some suggestions as to how I could word this?
 
A: It used to be very difficult to construct these types of queries, but the 2013 ACDIS/AHIMA physician query practice brief expanded the use of the yes/no query format—and this is the perfect situation for which to use it. The provider will likely have to respond on the query form when using a yes/no format so the query would need to be part of the medical record. Here is how I would pose the query:
 
Dear Dr. Bile Leak,
Is there a relationship between the bile leak and the cholecystectomy that occurred two weeks ago?
  • No
  • Yes
  • Unable to determine
  •  Other: __________
If you are uncomfortable with the yes/no format, or your queries are not kept as part of the medical record, you could pose a query as follows:
 
Dear Dr. Bile Leak,
Please clarify what, if any, relationship exists between the bile leak and the cholecystectomy that was performed two weeks ago.
  • The bile leak is related to the cholecystectomy
  • There is no relationship between the bile leak and cholecystectomy
  • Unable to determine
  • Other: __________
If your query forms are kept as a permanent part of the medical record then let the provider know. If not, be sure to prompt the provider to respond in the next progress note and/or the discharge summary.
 
You can change the wording to show the relationship between the bile leak and cholecystectomy as noted above (i.e., “related to”), but you could also say, “secondary to,” “from,” or other such terminology.  If the provider documents on the query form using either of the above formats, you must add a place for the provider’s signature, date, and time as the query form must then meet authentication requirements associated with any document within the medical record.
 
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.This article originally published on the ACDIS Blog.



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