CCDS CDI Strategies 4 — Questions and Answers
Question 1: 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?
- Submit a query asking the physician to clarify whether sepsis is present based on the clinical indicators (Correct answer)
- Assign the sepsis code based on the clinical evidence without querying
- Leave the documentation as-is to avoid bothering the physician
- Report the case to compliance for incomplete documentation
Correct 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.
Question 2: Which CDI strategy is MOST effective for improving physician query response rates?
- Sending queries only at discharge to avoid interrupting care
- Building relationships with physicians and educating them on the impact of documentation (Correct answer)
- Escalating all unanswered queries to the compliance department immediately
- Limiting queries to high-revenue DRGs only
Correct 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.
Question 3: A CDI team wants to prioritize which records to review first. Which approach represents BEST practice?
- Review all records alphabetically by patient last name
- Focus only on surgical cases regardless of clinical complexity
- Use a risk-stratified approach targeting high-complexity, high-LOS, or high-cost cases (Correct answer)
- Review records randomly to ensure unbiased selection
Correct 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.
Question 4: When a CDI specialist queries a physician about a possible principal diagnosis change, the physician does not respond. What is the APPROPRIATE next step?
- Code the diagnosis the CDI specialist believes is correct
- Follow the facility's escalation policy, which may include notifying a physician advisor (Correct answer)
- Discard the query and finalize coding without the clarification
- Contact the patient directly to determine the correct diagnosis
Correct 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.
Question 5: A CDI program wants to demonstrate its value to hospital administration. Which metric BEST reflects CDI impact on quality reporting?
- Number of queries issued per month
- Change in case mix index (CMI) over time
- Improvement in Present on Admission (POA) indicator accuracy and risk-adjusted mortality rates (Correct answer)
- Total physician satisfaction scores
Correct 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.
Question 6: Which situation would be MOST appropriate for a concurrent CDI review strategy rather than retrospective review?
- Reviewing records after final coding to identify missed diagnoses
- Auditing discharged patient records for compliance purposes
- Querying physicians while the patient is still admitted to capture real-time documentation (Correct answer)
- Reviewing claims after payer adjudication for denial management
Correct 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.
Question 7: 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?
- Code both conditions without querying since it is clinically obvious
- Query the physician to clarify whether acute respiratory failure is also present as a separate diagnosis (Correct answer)
- Ignore the acute respiratory failure since COPD is already documented
- Assign acute respiratory failure as the principal diagnosis without physician input
Correct 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.
CCDS CDI Strategies 4
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?