Q&A: Including “unable to clinically determine” in multiple choice queries

Q: One of my CDI specialists thought we needed the phrase “unable to clinically determine” as an option on every multiple choice query we send. My take on it is that if we have “other” with an option for free text, that would cover us for compliance. Further, I thought it was inappropriate to include this option in some cases, as it may offer an option that is preventing me from obtaining the detail and specificity I need. What are your thoughts?

A: More than likely, the instruction to include “unable to determine” came from a vendor or consultant, or a publication somewhere down the line. The rationale stems from the possibility that it could be considered leading if every option provided translates into a CC/MCC without any way to pick another option. 

I do believe the “other” option satisfies this requirement by giving the physician the opportunity to just write in or list his or her other diagnosis. Many best practice publications advise to give both “other” and “unable to determine,” or even include something like “clinically insignificant” or “disagree” as options. 

I usually try to give three or four clinically relevant options. Not all should be CCs or MCCs. They should be whatever diagnoses are clinically relevant or possible given the indicators. I often also include the language of “evidence of” or “possible” in parentheses in my multiple-choice query when the diagnosis cannot be easily confirmed but is a strong possibility based upon the evidence of clinical indicators and/or anytime I suspect the diagnosis has not been fully confirmed. I also include an “other” option.

 I try and discourage any type of query that I consider a “weak” query, but when I am addressing something like abnormal diagnostic findings, I find that to be the appropriate time to include choices such as “clinically insignificant.” If it’s suspected that there may not be enough evidence for the physician to add the increased specificity for an improved ICD-10 code, but I need to ask the query anyway, then the phrase “unable to determine” seems very appropriate. The choices given should be tailored so that they fit the specific circumstances at hand.  

Please note that the official guidance says “such as” which means they are only giving examples which the CDI specialist may find helpful. It does not say the specific choices should always be offered and generally offering inappropriate choices is discouraged. For example, when discussing sepsis, I cannot think of a single clinical scenario in which sepsis would be “clinically insignificant,” which also makes it appear to be an inappropriate choice. Another example might be when discussing cardiac electrophysiology study results regarding a simple heart conduction disorder that the cardiologists can easily answer. I would be disingenuous if I said “unable to determine” is really an appropriate choice here. Remember, we already offered “other” as an option. If needed, the physician can easily write in “unable to determine” or “clinically insignificant” as his “other” response.   

In order to keep a query brief and functional, you only have four or five choices to list in such a format. Use them wisely and make sure they are appropriate. Also, be aware that the advice in the guidance including the phrase “such as” (meaning that the listed phrases are by definition just examples and not requirements) speaks for itself. Auditors and others opinion on the matter do not change the language in the brief. It is what it is.

Editor’s note: Please note that an earlier version of this Q&A was later revised by the instructor to include more detail and further advice to the reader. Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.