AHIMA AHIMA Clinical Documentation Improvement 3

Question 1

What is 'query compliance' in CDI practice?

Accepted Answer

Adherence to established guidelines ensuring queries are non-leading, clinically supported, and properly documented

Answer

Query compliance refers to following established industry guidelines to ensure queries are ethical, non-leading, clinically supported, and appropriately formatted.

Question 2

Under UHDDS guidelines, which diagnoses should be reported as 'additional diagnoses' for inpatient encounters?

Accepted Answer

Conditions that are clinically evaluated, treated, or affect the management of the patient during the stay

Answer

UHDDS guidelines specify that additional diagnoses are conditions that require clinical evaluation, therapeutic treatment, diagnostic procedures, or affect nursing care/monitoring.

Question 3

What is the role of the Case Mix Index (CMI) trend in assessing CDI program effectiveness?

Accepted Answer

An increasing CMI after CDI implementation may suggest improved documentation capture of patient complexity

Answer

An upward trend in CMI following CDI program implementation often reflects better documentation of patient severity, not necessarily sicker patients.

Question 4

Which ICD-10-CM coding guideline instructs coders to code conditions to the 'highest degree of certainty' for inpatient settings?

Accepted Answer

The uncertain diagnosis guideline, allowing coding of conditions documented as 'possible' or 'probable' at discharge

Answer

For inpatient coding, ICD-10-CM guidelines allow coding of conditions documented as 'possible,' 'probable,' or 'suspected' at the time of discharge if no definitive diagnosis is established.

Question 5

What is 'severity of illness' (SOI) in the context of clinical documentation and reimbursement?

Accepted Answer

A measure of the extent of physiologic decompensation or organ system loss of function

Answer

Severity of illness reflects the degree of physiologic decompensation and is used in all-patient refined DRG (APR-DRG) systems to assess resource needs.

(AHIMA) American Health Information Management Association Practice Test

(AHIMA) American Health Information Management Association Practice Test

AHIMA AHIMA Clinical Documentation Improvement 3