Query answer states "unable to determine"

jlightfoot@marshallmedical.org

Hi all!

Our query templates have the option of "unable to determine". Just wondering if anyone has thoughts or coding clinic guidance on when a physician answers a query with "unable to determine". Does this mean the diagnosis is "possible" and can be coded if it is a post discharge query? Seems the diagnosis isn’t confirmed or ruled it out...

Thanks for any input.
Jillian Lightfoot, RN
Marshall Medical Center
Placerville, CA
(530) 626-2770 Ext. 6203
jlightfoot@marshallmedical.org

annnd2009@gmail.com

Hi

I think that would not hold in an audit. I assume you gave possible as
a choice. If not maybe include that to offer the option. I think docs
can use it as a "blow off" and deciding that means probable might get
you onto trouble.

Ann Donnelly,RN,CCDS

katysuegood@gmail.com

I think I know what you mean and often find these situations confusing as well. Obviously if the dx has not been stated by the MD, it can't be coded. But it becomes complex when you are querying for clarification of an already documented dx.

For example, we recently had a case where an alcoholic presented with hyperthermia, DIC, and evidence of (old) burns with SIRS criteria. The documentation states "sepsis and hemodynamic collapse including DIC related to hyperthermia". This is confusing. Are we meaning sepsis with DIC and hyperthermia with a suspected infectious source? Or are we really meaning SIRS 2/2 hyperthermia (our Docs tend to use SIRS/SEPSIS interchangeably regardless of education)? These are two very different things in the coding world even though they may not have been significantly different in the treatment of this patient (she was made comfort care and died in a matter of hours).
The CDI queried with the following query:
The medical record reflects the following clinical findings: Known alcoholic presents intoxicated with hyperthermia, DIC and recent 2nd and 3rd degree scald type burns. Patient was tachypneic, febrile, and tachycardic, with leukocytosis. Documenation states "sespis and hemodynamic collapse including DIC related to hyperthermia. Can you please clarify whether this patient had:

Sepsis (Systemic inflammatory response syndrome 2/2 to suspected infections)
Systemic inflammatory response syndrome (Systemic inflammatory response syndrome 2/2 to non infections source)
Other
Unable to determine

The MD responded with Unable to determine and said that she was being sent for autopsy.


Soooo.... what do we do with that? Sepsis IS in the record. Do we code it as is? I don’t have an answer, just commiserating with you on this one. The coder did code it as sepsis and I did not argue with that when I reviewed it as a death record retrospectively.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

jlightfoot@marshallmedical.org

We don't have possible on all of our queries, maybe we need to add that option or combine it with unable to determine.

It was definitely a "blow off" answer. Multiple clinical markers to support the diagnosis. I'm not recommending that the diagnosis be coded on this case, but it got me thinking; especially since I was aggravated at the doctor response!

Our lead coder and compliance are looking into it. I'll post if we find out anything definitive.

Thanks for your thoughts.

mark.michelman

In my experience, some of these query responses "unable to determine" are valid, but on the other hand, many physicians use this response as a "work around". They just don't want to spend the time to reopen up the medical record and search for the answer. When these responses are sent to me from my coding/clinical documentation team, invariably, I will find a definite response to the query. I then contact the physician and explain to him/her exactly where the response can be found. The query is then resent to the physician at which time they will respond with the more definitive answer.

Mark Michelman,MD,MBA
Vice President of Medical Affairs
Morton Plant Mease Health Care
BayCare Health System
Clearwater, Florida
727-461-8016

jlightfoot@marshallmedical.org

Sorry Katie, this got me laughing out loud. Yep, you get it! So, any thoughts on "unable to determine/possible" as an option?

For the record, I agree with coding the sepsis, it's a more specific diagnosis and there were supporting clinical findings.

Jillian Lightfoot RN
Clinical Documentation Team
Marshall Medical Center
Placerville, CA 95667
(530) 626-2770 Ext. 6203
jlightfoot@marshallmedical.org

vanessa.falkoff

Ours say "Unable to clinically determine" and if this response is checked when we (CDI) really believe the information is available to make a determination we refer the case to our physician advisor who calls the Doc. This has only happened once.

Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322

Compassion * Accountability * Respect * Integrity

catladyrn

I think it really depends on the context. Katy's example was really interesting, but even in that case, though the physician has written sepsis, if there's no support in the record for SIRS due to infection, it still might not fly, especially as the physician won't elaborate.

I'd be leery of introducing "possible" as one of your query responses. Because if they only answer it in the query and don't carry it through to discharge, you're going to have to query again to see if it's been ruled out, ruled in, or remains in the differential. I only ask for "possible" when I have a diagnosis that's already been written that way and I want to know if they've gotten around to making a determination, especially if the diagnosis just fell off the chart. So I ask if it's been ruled in, ruled out, resolved, or remains in the differential. What I would do with an "unable to determine," I don't know!

Renee

Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

annnd2009@gmail.com

I just wrote a pneumonia

Pneumonia -antibiotic selection to treat (type)_______
Possible pneumonia..(same as above
Pneumonia
Possible pneumonia
Pneumonia ruled out
Unable to determine
Other_____

julie.cruz-sje

We have started asking for specifics by including the following in our queries :
-Other (please state)
-Unable to determine (please state rationale)

Of course, other options are provided for them to choose. It is interesting when we ask for the rationale, we get fewer "unable to determines" and we have told our physicians they don't need to write a long explanation.....not enough history, labs etc.... will suffice. It just places the responsibility back on them to state their thought process in terms of diagnoses.

Julie Cruz RN, CDS

Clinical Documentation Specialist
St. Joseph Health
2700 Dolbeer St
Eureka, CA 95501
wk: 707-445-8121 ext. 7550
cell: 707-267-0973

axel.olson@essentiahealth.org

I have heard to avoid using the term "possible" in queries
and to use the term "evidence of" instead.

at the bottom of all of our queries we write:

Note: Use of probable, likely, suspected are all acceptable terms in the progress notes/discharge summary

Also,I agree with above writers that use of "unable to clinically determine" should be selective based on a case by case basis.

Axel Olson, RN, CDS
Clinical Documentation Improvement
Essentia Health