AHIMA Clinical Documentation Improvement Flashcards
6 cards from real AHIMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 AHIMA Clinical Documentation Improvement flashcards as text
What is the primary goal of a Clinical Documentation Improvement (CDI) program in a US hospital?
Answer: Ensure clinical documentation accurately reflects patient severity and resource utilization
CDI programs aim to ensure that clinical documentation accurately captures the patient's severity of illness and the resources used in their care.
Which query type asks a physician to clarify documentation without suggesting a specific diagnosis?
Answer: Non-leading query
A non-leading query presents clinical indicators and asks the physician to provide their clinical interpretation without suggesting an answer.
What does the term 'principal diagnosis' mean in the context of US inpatient coding under UHDDS guidelines?
Answer: The condition established after study to be chiefly responsible for the admission
The Uniform Hospital Discharge Data Set (UHDDS) defines the principal diagnosis as the condition established after study to be chiefly responsible for causing the admission.
Which condition must be documented by the physician for a CDI specialist to query for 'malnutrition' to affect MS-DRG assignment?
Answer: Clinical indicators such as poor intake, weight loss, or muscle wasting documented alongside a clinical diagnosis
Malnutrition requires a physician's clinical diagnosis supported by documented indicators; lab values alone are insufficient for coding purposes.
What is a 'concurrent' CDI review?
Answer: Review performed while the patient is still admitted
Concurrent CDI review occurs while the patient is still hospitalized, allowing queries to be answered before discharge and the record is coded.
Under ICD-10-CM/PCS guidelines, when is it appropriate to code a condition as 'present on admission' (POA)?
Answer: When the condition exists at the time the order for inpatient admission occurs
POA is defined as a condition present at the time the order for inpatient admission is made, including conditions that develop during an outpatient encounter that results in admission.