Guest post: Check yes or no

By Howard Rodenberg, MD, MPH, CCDS

“Do you love me? Do you want me? / Check yes or no.”—George Strait

Ah, the simple joys of childhood. I’m from the era where our grade school social network was mediated by small paper notes rocketing across the classroom. If it hit the wrong person, or eight, all of them would inspect the note before passing it along, making certain that everyone knew all before recess.

There’s a certain comfort to familiarity, which is probably why the childhood checkboxes have never really gone out of style. And it’s why the yes/no query is one of the easiest to write. You simply are trying to find out if the physician agrees with something someone else wrote. No need to come up with a lot of choices, no worry about word order, no risk of giving away the game by putting the preferred answer in the stem of the question. Piece of cake, slice of pie. (Pecan, if anyone’s asking.)

But because we’re CDI professionals, and we tend to make things complicated (continuing issues = job security), it seems to me that we’ve made the yes/no query harder than it has to be.

Let’s start with what should be on a yes/no query. According to the ACDIS/AHIMA 2019 “Guidelines for Achieving a Compliant Query Practice,” written queries should offer “…additional options that permit the provider to craft their own alternate response. Options may include other, unknown, unable to determine, not clinically significant, integral to, or other similar wording.”

This advice is placed within the general paragraph before the document outlines the different types of written queries, including those which are formatted as open-ended, multiple choice, or yes/no questions. In addition, the prior 2016 version of the same practice brief features a sample yes/no template including this language as well. (The 2019 document does not have a yes/no query template.) As a result of these factors, some CDI specialists feel that every query, including yes/no queries, need to include these choices.

I can understand that sometimes yes or no questions have answers other than yes or no. For example, let’s say Heidi Klum calls me up and asks me to lunch. On one hand, the answer is clearly yes, because, well, it’s Heidi Klum. On the other, the answer is no, because my girlfriend (the Beloved Dental Empress) is a huge Heidi Klum fan and she would be eternally annoyed that she didn’t get to come along so the two of them could discuss tall blonde things. So, in this case, the answer could clearly be “other” or “unable to determine,” at least without further information.

But with the kind of information we’re looking for in a yes/no query, I don’t think anything other than the two mutually exclusive choices of yes or no make sense. What we’re looking for is not an overall assessment of a situation, but simple agreement with a point of fact. The pathologist did say that biopsy showed cancer. The wound care nurse did say it was a stage 3 pressure ulcer. The registered dietician did use American Society for Parenteral and Enteral Nutrition (ASPEN) criteria and documented the presence of moderate malnutrition. We’re not asking the provider to make any more global decision or further probe the process of clinical judgment. We’re just asking if they agree.

The best analogy I can think of is trial by jury. You either agree with the prosecution or the defense, and anything other than “guilty” is functionally “not guilty.” Within this paradigm, choices such as “other” and “unable to determine” make no sense. These choices are really a “no,” as they offer you no other directions to turn to; and the use of these terms in a yes or no context is not only grammatically messy, but can cause confusion and dismay. So, wouldn’t it be a clearer statement of intent if we got rid of those options and made the yes/no query simply that?

Let’s encourage the next revision of the ACDIS/AHIMA query guidelines to address this conundrum. Or better yet, let’s amend the latest document to clarify any confusion. Isn’t that a good idea?

Check yes or no.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.