CCDS Healthcare Documentation 3

Question 1

A hospital implements a 'clinical documentation integrity' (CDI) program rather than calling it a 'clinical documentation improvement' program. What is the PRIMARY reason for this terminology shift?

Accepted Answer

CDI 'integrity' emphasizes accuracy and completeness rather than only upward DRG movement

Answer

CDI 'improvement' implies the original documentation was wrong, creating liability

Answer

The term 'improvement' is trademarked by AHIMA and cannot be used freely

Answer

CMS requires the term 'integrity' in program names for accreditation purposes

Question 2

Which documentation standard requires that every medical record entry be dated, timed, and authenticated by the responsible provider?

Accepted Answer

The Joint Commission (TJC) Medical Record Standards

Answer

ICD-10-CM Official Coding Guidelines

Answer

CMS MS-DRG Definitions Manual

Answer

AHIMA Standards of Ethical Coding

Question 3

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?

Accepted Answer

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

Answer

Copy-forward notes are prohibited by CMS and must be immediately reported to compliance

Answer

Copy-forward notes automatically void the authentication of subsequent notes

Answer

The attending will be penalized for duplicate documentation under Medicare billing rules

Question 4

Under the Medicare Conditions of Participation, which professional is ultimately responsible for the accuracy and completeness of the medical record?

Accepted Answer

The attending physician of record

Answer

The medical record director or health information manager

Answer

The hospital's compliance officer

Answer

The CDI specialist who reviewed the chart

Question 5

A hospitalist documents 'possible CHF exacerbation, probable pneumonia' in the discharge summary. How should the final codes reflect this?

Accepted Answer

Code both CHF exacerbation and pneumonia per the inpatient uncertain diagnosis guideline

Answer

Code only 'pneumonia' as it is the more specific of the two diagnoses

Answer

Code neither condition since both are uncertain

Answer

Code only the condition that results in the higher DRG

Question 6

Which of the following represents the BEST practice for a CDI specialist when a physician's query response is received after the claim has already been submitted?

Accepted Answer

Work with coding and billing to amend the claim if the response changes the coded diagnoses

Answer

Discard the query response since the claim is already submitted

Answer

Retroactively change the DRG without amending the medical record

Answer

File the response as an addendum but do not update the coded claim