Which type of query is the best option?

A clinical documentation integrity practitioner (CDIP) is looking for clarity on whether a diagnosis has been "ruled in" or "ruled out".

Which type of query is the best option?
A . Yes/No
B . None
C . Open-ended
D . Multiple-choice

View Answer

Answer: C

Explanation:

An open-ended query is a type of query that allows the provider to respond with free text, rather than choosing from a list of options or answering yes or no. An open-ended query is appropriate when the CDIP is looking for clarity on whether a diagnosis has been “ruled in” or “ruled out”, because it allows the provider to document the final diagnosis or impression based on the clinical evidence and reasoning. An open-ended query also avoids leading or suggesting a specific diagnosis to the provider, which could compromise the integrity and validity of the documentation. (Guidelines for Achieving a Compliant Query Practice (2019 Update) – AHIMA1)

References:

Guidelines for Achieving a Compliant Query Practice (2019 Update) – AHIMA1