CCDS Compliant Query Formulation 4

Question 1

A CDI specialist wants to query about the specificity of a patient's anemia. Which query format is MOST compliant with AHIMA/ACDIS guidelines?

Accepted Answer

A multiple-choice query listing anemia types with a blank for 'other' and 'clinically undetermined'

Answer

A multiple-choice format with 'clinically undetermined' as an option is the compliant standard per AHIMA/ACDIS query guidelines.

Question 2

Which of the following statements about query timing is MOST accurate under compliant query practices?

Accepted Answer

Queries may be issued concurrently during the encounter or retrospectively after discharge

Answer

Both concurrent (during admission) and retrospective (post-discharge) queries are permissible under compliant query guidelines.

Question 3

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

Accepted Answer

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

Answer

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

Question 4

Under AHIMA's 2019 compliant query guidelines, which of the following must be included in every written query?

Accepted Answer

Patient name, account number or date of service, and the clinical indicators supporting the query

Answer

AHIMA guidelines require patient identifiers, relevant clinical indicators, and a clear question with balanced response options.

Question 5

A CDI specialist documents in the query that clarifying a diagnosis to 'acute kidney injury' will increase reimbursement by $4,000. This practice is:

Accepted Answer

Non-compliant because queries must not reference financial impact or DRG changes

Answer

Including financial impact or DRG information in a query is non-compliant and can constitute improper influence on physician documentation.

CCDS - Certified Clinical Documentation Specialist Practice Test