CDIP - Certified Documentation Improvement Practitioner Physician Query Process Questions and Answers

Question 1

A CDI professional reviews a record where the physician documented 'heart failure'.
The echocardiogram shows an ejection fraction of 35% and the patient is on carvedilol and furosemide.
Which of the following is the most compliant query to send to the physician?

Accepted Answer

"Based on the clinical indicators, can the type and acuity of the heart failure be further specified?"

Answer

"The patient's ejection fraction is 35%. Please document acute on chronic systolic heart failure."

Answer

"Is the patient's low ejection fraction of 35% indicative of systolic heart failure for better reimbursement?"

Answer

"This patient has heart failure. Is it systolic, diastolic, or combined?"

Question 2

According to the AHIMA/ACDIS Practice Brief, which of the following is an essential element of a compliant multiple-choice query?

Accepted Answer

Providing an option such as 'other' or 'unable to determine' to allow the provider to add a free-text response.

Answer

Including at least five clinically valid options to choose from.

Answer

Listing the option with the highest reimbursement impact first.

Answer

Including ICD-10 codes next to each diagnostic option for clarity.

Question 3

A CDI specialist identifies conflicting documentation in a patient's chart. The emergency department physician documented 'pneumonia', while the hospitalist's progress note suggests 'acute exacerbation of CHF'. What is the primary purpose of initiating a physician query in this scenario?

Accepted Answer

To resolve the discrepancy to ensure accurate code assignment and reflection of the patient's condition.

Answer

To force the physicians to agree on a single diagnosis.

Answer

To determine which physician's documentation is more credible.

Answer

To educate the emergency department physician on the signs of CHF.

Question 4

Which of the following situations would NOT be an appropriate reason to initiate a physician query?

Accepted Answer

The CDI specialist believes a more specific diagnosis could be documented to increase the Case Mix Index (CMI).

Answer

The physician documents a diagnosis of sepsis, but there are no clinical indicators such as fever, tachycardia, or elevated WBC in the record.

Answer

The medical record contains illegible handwriting for the principal diagnosis.

Answer

The link between a patient's diabetes and a newly developed foot ulcer is not clearly documented.

Question 5

A patient's lab results show a sodium level of 125 mEq/L (low), and the physician has documented 'electrolyte imbalance'. A CDI specialist wants to query for a more specific diagnosis. Which query format is most appropriate and compliant?

Accepted Answer

An open-ended query stating: 'The patient's sodium is 125 mEq/L. Based on your clinical judgment, can this condition be further specified?'

Answer

A Yes/No query stating: 'Do you agree the patient has hyponatremia?'

Answer

A verbal query telling the physician to 'please add hyponatremia'.

Answer

A multiple-choice query with 'hypernatremia' and 'hypokalemia' as options.

Question 6

What is the best practice for a CDI department to follow when a physician consistently does not respond to queries?

Accepted Answer

Implement and follow a formal escalation policy that may involve a physician advisor.

Answer

Report the physician to the Chief Financial Officer for impeding revenue.

Answer

Discontinue sending queries to that specific physician.

Answer

Automatically code the chart using the most specific diagnosis suggested in the unanswered query.