CCDS Compliant Query Formulation 5

Question 1

When querying about the type of heart failure, which response option MUST always be included in a compliant multiple-choice query?

Accepted Answer

Clinically undetermined

Answer

Every compliant multiple-choice query must include 'clinically undetermined' to allow the physician to indicate that the condition cannot be specified.

Question 2

A query asks a physician: 'Based on the elevated creatinine, BUN, and oliguria, does the patient have acute kidney injury?' This is an example of a:

Accepted Answer

Compliant query because it presents clinical evidence without steering toward a specific answer

Answer

Presenting objective clinical indicators (labs, vitals, symptoms) to support the query is compliant when no specific answer is implied.

Question 3

Which action by a CDI specialist most likely constitutes 'query harassment' under professional guidelines?

Accepted Answer

Sending repeated queries to the same physician on the same encounter after receiving a 'clinically undetermined' response

Answer

Requerying a physician on the same issue after receiving a valid 'clinically undetermined' response is considered query harassment and is non-compliant.

Question 4

A CDI specialist notices a physician documents 'urosepsis' in the record. Under ICD-10-CM coding guidelines, the appropriate next step is to:

Accepted Answer

Query the physician to clarify whether sepsis due to a urinary tract infection or UTI alone is intended

Answer

ICD-10-CM guidelines state that 'urosepsis' is not a codeable term and requires physician clarification to distinguish sepsis from UTI.

Question 5

Which of the following BEST describes the 'clinical validity' principle as it applies to compliant query formulation?

Accepted Answer

A query should only be submitted when objective clinical evidence in the record supports the possibility of the condition being queried

Answer

Clinical validity requires that queries be grounded in documented clinical evidence, not assumptions or financial motivations.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Compliant Query Formulation 5