Multiple clinically reasonable explanations exist for an abnormal clinic finding, but the coder sends a yes/no query naming only one diagnosis. What is the better practice?
Select an answer to reveal the explanation.
Short Explanation
Yes/no works when the world really is binary. When several diagnoses could fit, a one-disease yes/no steers the chart. Give real alternatives—including “undetermined”—and keep the query honest.
Full Explanation
Yes/no queries are appropriate only in limited circumstances, such as confirming a specific documented item. When multiple clinically reasonable options exist, ethical practice favors presenting those options concurrently (including undetermined/cannot be determined) so the provider is not steered toward a single suggested diagnosis. Narrow yes/no wording that introduces one preferred condition is treated as leading.