What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in
A yes/no query may not be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record because it may lead to leading or suggesting a diagnosis that is not supported by the provider’s documentation. A yes/no query should only be used when there is clear and consistent documentation of a condition/diagnosis in the health record, and the query is seeking confirmation or denial of a specific fact or detail related to that condition/diagnosis. A multiple-choice, open-ended, or verbal query may be more appropriate to allow the provider to choose from a list of possible diagnoses, provide additional information, or explain the clinical reasoning behind the documentation. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3
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