CCDS CDI Strategies 5

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?

Accepted Answer

Morbid (severe) obesity or Class III obesity to reflect the clinical severity accurately

Answer

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?

Accepted Answer

Begin with a physician champion and pilot the program in a high-volume service line

Answer

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?

Accepted Answer

A non-leading, multiple-choice query presenting acute-on-chronic heart failure, acute exacerbation of CHF, fluid overload, or unable to determine

Answer

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?

Accepted Answer

A consistently high rate of 'unable to determine' physician responses to queries

Answer

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?

Accepted Answer

'Y' means the condition was present at admission; 'W' means clinically undetermined at time of admission

Answer

'Y' (yes) means the condition was present on admission, while 'W' (clinically undetermined) is used when it cannot be determined based on available documentation.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS CDI Strategies 5