Q&A: Unable to determine query

Question: I am a little confused regarding the meaning “clinically undetermined” or “unable to determine” as a query choice. If a physician chooses unable to determine, does it mean the provider disagrees with the presented choices or disagrees with a diagnosis entirely? For example, if the physician has documented pneumonia in the medical record, a query is placed for specification of the type of pneumonia, and the provider replies unable to determine, how is that interpreted?

A: The 2022 update of the Guidelines for Achieving a Compliant Query Practice brief has clarified that CDI specialists do not need to include “unable to clinically determine” in their multiple-choice query choices, unless the query specifically needs to have it included, such as when querying for a hospital-acquired condition (e.g., POA-Y, POA-N, or POA-Unable to be determined), or unless your organization has a policy that “unable to clinically determine” is a required choice.

In the scenario you present, with a provider unable to determine if pneumonia is simple or complex, the provider has answered the query but has not agreed or disagreed. Most electronic query provider responses include “alternate response.” I am not a fan of “no codable response” because the provider has responded in their best judgment and cannot always make a definitive diagnosis based on the patient’s presentation, such as in this case. Every organization handles these responses differently, so I think the best course of action is to ask your CDI leadership if there is a department guideline or policy.

Editor’s note: Kim Conner, BSN, CCDS, CCDS-O, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at kconner@hcpro.com.