Query Tip: The Many Meanings of "Unable to Determine" – HIAcode

Queries written in a multiple-choice format include a short list of options for physician response. These options must be relevant and supported by the clinical indicators included in the query. In the event a physician cannot provide further specificity by using one of these listed options, there must be an additional option for “unable to determine.” “Unable to determine” (or similar phrases such as “undetermined” or “unspecified”) may have different meanings, depending on the query objective.

(PLEASE NOTE:  The examples below only contain the question and options for response.  The coder would also need to include any relevant clinical indicators to support the query.)

POA Query

“Unable to determine” means the physician cannot confirm that the condition was present at the time of admission. This response is only addressing the POA status, not if the condition is ruled in or ruled out. The condition would not be used as principal diagnosis with a POA status of “unable to determine.”

Question:  Was pneumonia present at the time of admission?

• Yes
• No
• Unable to determine

Ruled In/Ruled Out Query

In this type of query, a response of “unable to determine” is interpreted as stating the condition is suspected or possible. Coding will be guided by the guidelines for Uncertain Diagnosis Section II.H and Section III.C.

Question:  Can you confirm the diagnosis of pneumonia?

*Pneumonia was ruled in
*Pneumonia was ruled out
*Other (specify _________________)
*Unable to determine

Further Specificity Query

Many times further specificity is required for a condition, such as acuity or type. In these cases, a response of “unable to determine” is essentially stating “unspecified.” For the example below, there would be no need to include a separate option for “Pneumonia, unspecified” as “unable to determine” also indicates there will be no further specificity for the type of pneumonia.

Question:  Can you further specify the organism responsible for pneumonia?

*Bacterial pneumonia (specify organism____________)
*Viral pneumonia (specify organism ____________)
*Other (specify _______________)
*Unable to determine 

The information contained in this query advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.