Q&A: Querying uncertain diagnoses

Q: Can we send a concurrent query to the physician using the statement within the query: "Use of terms such as concern for, suspected, possible, or probable (associated with a specific diagnosis) are accepted and can be coded in the inpatient setting”? I was told that this type of query should only be used at discharge.

For example, if documentation states pneumonia and I see the patient is receiving an antibiotic used to treat gram-negative bacteria and send a query for the suspected, possible, probable type of pneumonia they are treating with this language:

As the attending provider and based on the clinical picture and antibiotic choice, please clarify the most likely type of suspected pneumonia (even if specific organism may not be known). 

• Use of terms such as concern for, suspected, possible, or probable (associated with a specific diagnosis) are accepted and can be coded in the inpatient setting

Query response options were then listed for the physician to choose from. Does the above example appear to be compliant? Can this type of query be utilized concurrently or only at discharge?

A: CDI specialists need to spend time educating providers prior to and continuously throughout the query process. Part of the education includes that the physician should link the pneumonia to the causative organism whenever possible and that the identification of the organism may be based on the patient’s history, presentation, or treatment protocol. They also need to be educated that although positive blood cultures are great to have, they are not necessary for the diagnosis of pneumonia or any diagnosis/condition. It is just as important to educate the providers that they may use verbiage such as “likely or probable” if they are uncertain about the diagnosis or the causative organism.

Another important point is to encourage the providers to incorporate the preliminary microbiology report regarding the blood culture results into their progress note. The microbiology department has someone calling or sending this preliminary report to the provider within 24 to 48 hours. It is usually the sensitivity testing that takes longer, not the identification of the organism. Blood cultures are then finalized after seven days if nothing fails to grow.

You are correct that certain antibiotics are ordered for certain types of pneumonia. A good resource for this information is the pharmacist at your facility.

When looking at your query example, it seems a little clunky to me. If pneumonia is already documented in the medical record and you would like to clarify the specificity of the pneumonia, you could do that within the answer options, not the stem of the query question (which I feel could be a little confusing).

Here is how I would structure the query:

Dr. (Attending),

Based on the order (date) for (antibiotic/route), (then state any other clinical indicators you may have and where in the record this information was found), could you please clarify the type of pneumonia?

• Probable gram-negative pneumonia
• Other explanation of clinical findings (please specify):________

Then, below the query scenario and answer options you provide, I would include your physician tip, as we want the query to be clear and concise:

Use of terms such as concern for, suspected, possible, or probable (associated with a specific diagnosis) are accepted and can be coded in the inpatient setting

I have not heard of a rule before that prohibits a concurrent query from using the “uncertain” verbiage, but I would check to see if your organization has some internal rule that prohibits it. I think some are concerned that if you use uncertain verbiage in a query and the physician chooses an answer option with it, they will not carry it through to discharge.

The Official ICD-10-CM/PCS Guidelines for Coding and Reporting state that if a condition is uncertain during the encounter, it has to be documented as such at the time of discharge, meaning either the discharge summary or the last progress note if no discharge summary is present for it to be coded. This is why I think some may think this type of query should only be used after discharge. So, the physicians will also have to be educated if they use an uncertain term during the hospital stay. They must continue to use the verbiage through to discharge, unless at some point during the stay they confirm the diagnosis/condition.

Editor’s note: Sharme Brodie, RN, CCDS, CCDS-O, CRC, CDI education specialist for ACDIS/HCPro, based in Middleton, Massachusetts, answered this question. Contact her at sbrodie@acdis.org.