CCDS CDI Strategies 5 — Questions and Answers
Question 1: A CDI specialist is reviewing a patient with a BMI of 42 and the physician documents 'obesity.' What additional documentation should the CDI specialist query for?
- The patient's diet history
- Morbid (severe) obesity or Class III obesity to reflect the clinical severity accurately (Correct answer)
- Whether the patient has ever dieted
- The patient's weight loss goals
Correct answer: Morbid (severe) obesity or Class III obesity to reflect the clinical severity accurately
A BMI of 40 or greater qualifies as morbid (severe) obesity, and querying for this specificity affects DRG assignment and severity of illness reporting.
Question 2: Which CDI strategy is MOST effective when implementing a new CDI program in a facility with low physician engagement?
- Mandate query responses within 24 hours through a new hospital policy immediately
- Begin with a physician champion and pilot the program in a high-volume service line (Correct answer)
- Focus exclusively on retrospective record review until engagement improves
- Limit CDI activity to the emergency department only
Correct answer: Begin with a physician champion and pilot the program in a high-volume service line
Engaging a physician champion and piloting in a focused area builds credibility and early wins that encourage broader physician buy-in.
Question 3: A CDI specialist finds that a patient with heart failure has a BNP of 900 pg/mL and required IV diuresis, but the physician only documents 'fluid overload.' What type of query is MOST appropriate?
- A leading query suggesting the physician document congestive heart failure
- A non-leading, multiple-choice query presenting acute-on-chronic heart failure, acute exacerbation of CHF, fluid overload, or unable to determine (Correct answer)
- No query because the physician's documentation is sufficient
- A verbal query demanding the physician change the diagnosis
Correct answer: A non-leading, multiple-choice query presenting acute-on-chronic heart failure, acute exacerbation of CHF, fluid overload, or unable to determine
Compliant queries must be non-leading and offer multiple options including 'unable to determine,' allowing the physician to make the clinical judgment.
Question 4: When tracking CDI program performance, which trend would indicate a PROBLEM with query compliance?
- A high rate of physician agreement with CDI query options
- A consistently high rate of 'unable to determine' physician responses to queries (Correct answer)
- Increasing case mix index over successive quarters
- Decreasing length of stay with stable documentation quality scores
Correct answer: A consistently high rate of 'unable to determine' physician responses to queries
A high rate of 'unable to determine' responses may indicate that queries are being issued without sufficient clinical evidence to support the queried diagnosis.
Question 5: A CDI specialist is educating a new team member about the difference between a 'present on admission' (POA) indicator of 'Y' versus 'W.' Which statement is CORRECT?
- 'Y' means the condition was not present at admission; 'W' means it was present
- 'Y' means the condition was present at admission; 'W' means clinically undetermined at time of admission (Correct answer)
- 'W' means the condition was a hospital-acquired complication; 'Y' means it was not
- Both indicators have the same impact on quality reporting
Correct answer: 'Y' means the condition was present at admission; 'W' means clinically undetermined at time of admission
'Y' (yes) means the condition was present on admission, while 'W' (clinically undetermined) is used when it cannot be determined based on available documentation.
Question 6: Which approach BEST supports CDI success in capturing malnutrition documentation?
- Querying only when the patient has a BMI below 18
- Collaborating with dietitians to identify patients meeting malnutrition criteria and then querying the physician (Correct answer)
- Coding malnutrition based on low albumin levels alone without a query
- Waiting until discharge to query the physician about nutritional status
Correct answer: Collaborating with dietitians to identify patients meeting malnutrition criteria and then querying the physician
Interdisciplinary collaboration with dietitians helps CDI specialists identify malnutrition criteria (per ASPEN guidelines) and support timely, evidence-based physician queries.
Question 7: A CDI program is expanding to cover outpatient records in addition to inpatient. What is the PRIMARY difference in CDI strategy for outpatient versus inpatient records?
- Outpatient CDI focuses on DRG optimization while inpatient focuses on APC accuracy
- Outpatient CDI must adhere to the UHDDS guidelines, while inpatient follows APC guidelines
- Outpatient CDI focuses on coding to the highest degree of certainty documented, avoiding uncertain diagnoses, while inpatient allows coding of 'probable' conditions (Correct answer)
- There is no difference — the same CDI rules apply to both settings
Correct answer: Outpatient CDI focuses on coding to the highest degree of certainty documented, avoiding uncertain diagnoses, while inpatient allows coding of 'probable' conditions
In outpatient settings, coding guidelines prohibit assigning diagnoses qualified as 'probable' or 'suspected,' requiring confirmed diagnoses only, unlike inpatient guidelines.
CCDS CDI Strategies 5
A CDI specialist is reviewing a patient with a BMI of 42 and the physician documents 'obesity.' What additional documentation should the CDI specialist query for?