CDI Strategies Flashcards
7 cards from real CCDS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 CDI Strategies flashcards as text
A CDI specialist notices a patient was admitted with sepsis but the physician only documented 'fever and hypotension.' What is the BEST initial CDI strategy?
Answer: Submit a query asking the physician to clarify whether sepsis is present based on the clinical indicators
CDI specialists should submit a compliant query when clinical indicators support a more specific diagnosis that the physician has not explicitly documented.
Which CDI strategy is MOST effective for improving physician query response rates?
Answer: Building relationships with physicians and educating them on the impact of documentation
Physician education and relationship-building are proven strategies for improving query response rates and overall documentation quality.
A CDI team wants to prioritize which records to review first. Which approach represents BEST practice?
Answer: Use a risk-stratified approach targeting high-complexity, high-LOS, or high-cost cases
Risk stratification ensures CDI resources are directed toward cases with the greatest documentation improvement opportunities and financial or quality impact.
When a CDI specialist queries a physician about a possible principal diagnosis change, the physician does not respond. What is the APPROPRIATE next step?
Answer: Follow the facility's escalation policy, which may include notifying a physician advisor
Facilities should have escalation policies that include physician advisors or medical staff leadership to address non-responsive physicians.
A CDI program wants to demonstrate its value to hospital administration. Which metric BEST reflects CDI impact on quality reporting?
Answer: Improvement in Present on Admission (POA) indicator accuracy and risk-adjusted mortality rates
Accurate POA indicators and improved risk-adjusted mortality rates reflect CDI's impact on quality measures and hospital reputation beyond financial metrics.
Which situation would be MOST appropriate for a concurrent CDI review strategy rather than retrospective review?
Answer: Querying physicians while the patient is still admitted to capture real-time documentation
Concurrent review allows CDI specialists to query physicians during the active hospital stay, improving documentation before discharge and coding.
A CDI specialist reviews a record where a patient has both acute respiratory failure and COPD exacerbation. The physician documents only 'COPD exacerbation.' What is the CDI specialist's BEST action?
Answer: Query the physician to clarify whether acute respiratory failure is also present as a separate diagnosis
When clinical indicators suggest an additional diagnosis like acute respiratory failure, a compliant query to the physician is required before coding it.