CDIP - Certified Documentation Improvement Practitioner Clinical Validation Principles Questions and Answers

Question 1

A CDI specialist reviews a record where the physician documented 'acute respiratory failure'.
The patient's vital signs are stable, with a respiratory rate of 18 and an oxygen saturation of 96% on room air.
There is no ABG result, and the physical exam notes clear breath sounds.
Which of the following is the most appropriate action?

Accepted Answer

Initiate a clinical validation query presenting the objective clinical findings and asking the provider to confirm or clarify the diagnosis.

Answer

Ignore the diagnosis as it is not clinically supported and will likely be denied.

Answer

Report the physician to the compliance department for documenting an unsubstantiated diagnosis.

Answer

Accept the diagnosis based on the physician's statement, as code assignment is based on provider documentation.

Question 2

What is the fundamental difference between a clinical validation query and a clinical clarification query?

Accepted Answer

A validation query questions if a documented diagnosis is supported by clinical evidence, while a clarification query seeks more specificity for a supported diagnosis.

Answer

Validation queries are only used for MCCs, while clarification queries are used for CCs.

Answer

Validation queries are a responsibility of the coding department, while clarification queries are handled by the CDI department.

Answer

Clarification queries can be verbal, but validation queries must always be in writing.

Question 3

A physician documents 'severe protein-calorie malnutrition'. Upon review, the CDI specialist notes a BMI of 23, albumin of 3.9 g/dL, and consistent documentation of 'good oral intake' by nursing. A validation query is sent, but the physician does not respond. According to CDI best practices, what is the most appropriate next step?

Accepted Answer

Follow the established escalation policy, which typically involves referral to a physician advisor.

Answer

Instruct the coder to remove the diagnosis code since the query was not answered.

Answer

Send the same query to the physician a second time with a note indicating it is urgent.

Answer

Close the case and take no further action, assuming the physician's silence indicates agreement.

Question 4

The primary goal of the clinical validation process is to:

Accepted Answer

Ensure the health record accurately reflects the patient's true clinical condition and the care provided.

Answer

Maximize hospital reimbursement by ensuring all possible MCCs are captured.

Answer

Challenge the clinical judgment of physicians to improve their diagnostic accuracy.

Answer

Solely prevent claim denials from third-party payers.

Question 5

A CDI specialist is reviewing a record with a documented diagnosis of sepsis. Which of the following sets of clinical findings would most likely trigger a clinical validation query due to a lack of supporting evidence?

Accepted Answer

Normal white blood cell count, consistently afebrile, and stable vital signs throughout the admission.

Answer

Hypotension, altered mental status, and a positive blood culture.

Answer

Documented source of infection, elevated lactate, and acute kidney injury.

Answer

Fever, tachycardia, and leukocytosis.

Question 6

Which of the following is an essential component of a compliant, non-leading clinical validation query?

Accepted Answer

Presenting the objective clinical evidence from the record and asking the provider for clarification.

Answer

Suggesting an alternative diagnosis that is better supported by the clinical indicators.

Answer

Citing external clinical criteria that the provider may not have used.

Answer

Asking the provider to remove the unsubstantiated diagnosis from the problem list.