Mixed Deck — All CCDS Topics Flashcards

A patient admitted for sepsis is also documented to have disseminated intravascular coagulation (DIC). What additional code is assigned?

Answer: D65 – Disseminated intravascular coagulation

DIC is an associated organ dysfunction that must be coded separately (D65) in addition to the sepsis code per ICD-10-CM guidelines.

A hospital receives a RAC (Recovery Audit Contractor) audit finding that a HAC was incorrectly assigned POA indicator 'Y' when clinical evidence supported 'N.' What is the primary financial risk to the hospital?

Answer: Recoupment of the MS-DRG overpayment received

If a RAC finds that a HAC should have been POA 'N,' the hospital faces recoupment of any overpayment because the MS-DRG would have been lower.

What does a high CC and MCC capture rate indicate about a CDI program?

Answer: The CDI program is effectively identifying and documenting secondary diagnoses

A high CC/MCC capture rate reflects that the CDI program is successfully identifying and ensuring documentation of significant secondary diagnoses that affect patient severity and resource utilization.

How do pericarditis and myocarditis differ in terms of CDI documentation requirements?

Answer: Both have distinct ICD-10-CM categories and both benefit from etiology documentation

Pericarditis and myocarditis involve different anatomic structures and have distinct ICD-10-CM categories; documenting etiology (viral, bacterial, autoimmune) for both enables more specific code assignment.

Which clinical documentation element would MOST strongly support a query for septic shock in a patient who is already coded with sepsis?

Answer: Documentation of vasopressor administration to maintain hemodynamic stability AND lactate above 2 mmol/L despite resuscitation

Septic shock requires both vasopressor dependence for MAP maintenance AND lactate above 2 mmol/L despite adequate fluid resuscitation. Both elements must be documented and cited in the query to support the septic shock diagnosis and R65.21 coding.

A physician documents 'urosepsis' for a patient with a UTI and fever but no organ dysfunction. What is the CDI specialist's best action?

Answer: Query the physician because Sepsis-3 requires evidence of organ dysfunction

Sepsis-3 requires life-threatening organ dysfunction in addition to infection, so 'urosepsis' without organ dysfunction should prompt a clarification query.

Why is documenting 'toxic metabolic encephalopathy' (TME) clinically superior to 'altered mental status' from a CDI perspective?

Answer: TME qualifies as a major complication or comorbidity (MCC), while AMS does not, affecting MS-DRG assignment

Toxic metabolic encephalopathy maps to an MCC under ICD-10-CM, which can significantly impact the MS-DRG weight and reimbursement. 'Altered mental status' is a symptom code that does not carry MCC status, leaving clinical complexity uncaptured.

Under Sepsis-3, the term 'severe sepsis' has been eliminated as a clinical definition. How does this affect ICD-10-CM coding practice?

Answer: ICD-10-CM still uses R65.20/R65.21 for severe sepsis and septic shock, which are coded based on physician documentation regardless of Sepsis-3 terminology

Although Sepsis-3 eliminated 'severe sepsis' as a clinical term, ICD-10-CM retains R65.20 (severe sepsis without septic shock) and R65.21 (severe sepsis with septic shock). Coding follows physician documentation.

A query is sent to a physician asking: 'Do you agree the patient has sepsis?' This query is problematic primarily because it:

Answer: Is a leading yes/no query that suggests a specific diagnosis without balanced options

Leading yes/no queries that suggest a specific answer are non-compliant because they bias the physician's response.

When querying about the type of heart failure, which response option MUST always be included in a compliant multiple-choice query?

Answer: Clinically undetermined

Every compliant multiple-choice query must include 'clinically undetermined' to allow the physician to indicate that the condition cannot be specified.

What documentation is required to code heart failure as 'systolic' rather than unspecified in ICD-10-CM?

Answer: Physician documentation of systolic heart failure

ICD-10-CM requires physician documentation of systolic heart failure; clinical findings and test results alone are insufficient for code assignment by coders.

A patient undergoes a laparoscopic cholecystectomy that is converted to an open procedure. How should this be coded in ICD-10-PCS?

Answer: Code only the open approach since it was the completed procedure

Per ICD-10-PCS guidelines, when a procedure is converted from a laparoscopic to an open approach, only the open approach procedure code is assigned. The laparoscopic portion that did not complete the intended procedure is not separately coded.

A CDI specialist uses a 'working DRG' during concurrent review. What is the PRIMARY purpose of the working DRG?

Answer: To predict the expected MS-DRG assignment based on current documentation

The working DRG is a real-time projection of the likely MS-DRG assignment based on documentation available during the stay. It helps CDI specialists identify gaps where additional physician documentation could support a more accurate DRG.

A CDI specialist is reviewing a medical record that contains a 'copy-forward' note where the attending copied the previous day's assessment unchanged for three consecutive days. What is the primary concern?

Answer: The notes may not accurately reflect the patient's current clinical status, risking documentation inaccuracy

Copy-forward or cloned notes that replicate previous documentation without reflecting the patient's current status create a documentation integrity risk. They may not accurately capture clinical changes.

From a CDI perspective, why does accurate secondary diagnosis documentation have an even greater impact in APR-DRGs than in MS-DRGs?

Answer: APR-DRGs use secondary diagnoses to assign SOI and ROM subclasses, which directly affect the payment weight for each case

In APR-DRGs, each secondary diagnosis is evaluated for its contribution to SOI and ROM subclass assignment. A single well-documented comorbidity can elevate a case from SOI 2 (Moderate) to SOI 3 (Major), substantially changing expected resource use and reimbursement — an effect more granular than MS-DRG's binary MCC/CC distinction.

A CDS has sent two compliant, well-supported queries to a physician regarding the etiology of a patient's anemia, but has received no response. What is the most appropriate next step according to standard CDI practice?

Answer: Follow the department's escalation policy, which may involve notifying the CDI manager or physician advisor.

A formal escalation process ensures that important documentation gaps are addressed while maintaining a professional and standardized approach. This usually involves a physician advisor who can engage the non-responsive physician in a peer-to-peer conversation.

Which of the following is a key difference between the ICD-10-CM definition of 'severe sepsis' (R65.2x) and the Sepsis-3 clinical definition?

Answer: Sepsis-3 eliminated the term 'severe sepsis'; ICD-10-CM retains it for coding purposes

Sepsis-3 eliminated 'severe sepsis' as a clinical category, but ICD-10-CM continues to use R65.20/R65.21 for coding organ dysfunction associated with sepsis.

When analyzing CC/MCC capture rates by physician, a CDI analyst finds that one physician has a significantly lower capture rate than peers. What is the MOST appropriate next step?

Answer: Conduct a focused chart review to determine if documentation gaps or coding issues are the cause

Before taking any action, the CDI analyst should conduct a focused review of the physician's charts to determine whether the low capture rate reflects documentation deficiencies, a legitimately less-complex patient mix, or coding issues.

Which nutritional marker is LEAST reliable for diagnosing acute malnutrition because it is heavily influenced by inflammation?

Answer: Serum albumin

Serum albumin is a negative acute-phase reactant; inflammation drives it down independent of nutritional status, making it unreliable for diagnosing acute malnutrition.

Which CMS value-based purchasing program penalizes hospitals for excess readmissions within 30 days for specific conditions?

Answer: Hospital Readmissions Reduction Program

The Hospital Readmissions Reduction Program (HRRP) reduces Medicare payments to hospitals with excess 30-day readmissions for conditions such as AMI, heart failure, and pneumonia.