CDIP - Certified Documentation Improvement Practitioner Record Review and Clarification Questions and Answers

Question 1

A CDI professional reviews a record where a patient with a history of hypertension presents with shortness of breath, an ejection fraction of 30%, and is treated with IV diuretics.
The physician has documented 'heart failure'.
According to the 2022 AHIMA/ACDIS Practice Brief, which of the following is the most compliant query format to clarify the type and acuity of the heart failure?

Accepted Answer

A multiple-choice query providing clinically supported options such as 'Acute systolic heart failure,' 'Chronic systolic heart failure,' 'Acute on chronic systolic heart failure,' and 'Unable to determine.'

Answer

A 'Yes/No' query asking, 'Is the patient experiencing acute on chronic systolic heart failure?'

Answer

A leading query suggesting, 'Based on the EF of 30% and IV diuretic use, please document acute systolic heart failure.'

Answer

An open-ended query stating, 'Please document a more specific diagnosis for the patient's heart failure to ensure proper reimbursement.'

Question 2

During a concurrent record review, a CDI specialist identifies conflicting documentation regarding the cause of a patient's acute kidney injury (AKI). The emergency department physician documented 'AKI due to dehydration,' while the hospitalist noted 'AKI, likely due to ATN (Acute Tubular Necrosis).' What is the primary purpose of initiating a query in this scenario?

Accepted Answer

To resolve the conflicting documentation and ensure the health record is accurate and consistent.

Answer

To educate the emergency department physician on the pathophysiology of ATN.

Answer

To determine which diagnosis will result in a higher MS-DRG assignment.

Answer

To have the hospitalist confirm the final diagnosis for coding purposes.

Question 3

Which of the following is a key principle of a compliant, non-leading physician query?

Accepted Answer

Citing specific clinical indicators from the patient's current health record to support the need for clarification.

Answer

Including the potential impact on quality scores to emphasize the importance of the query.

Answer

Suggesting a diagnosis that is not yet documented but is suspected by the CDI professional.

Answer

Using a yes/no format to obtain a new diagnosis when only clinical indicators are present.

Question 4

A CDI specialist is creating a query for a patient with documented anemia, a hemoglobin of 6.8 g/dL, and a positive fecal occult blood test. The physician has not linked the anemia to the suspected GI bleed. Which query statement is the most appropriate and non-leading?

Accepted Answer

'Based on the hemoglobin of 6.8 g/dL and positive FOBT, can you please clarify the cause and/or acuity of the patient's anemia?'

Answer

'Please document acute blood loss anemia due to GI bleed, as this will more accurately reflect the patient's severity of illness.'

Answer

'Is the documented anemia due to acute blood loss from a GI bleed? (Yes/No)'

Answer

'Per coding guidelines, the relationship between the anemia and the GI bleed must be established. Please link these conditions.'

Question 5

When is it appropriate for a CDI professional to use a verbal query?

Accepted Answer

When a case is complex and may require a back-and-forth discussion to clarify multiple points.

Answer

When the CDI professional wants to avoid creating a permanent record of the interaction.

Answer

When a quick 'yes' or 'no' answer is needed to add a new diagnosis.

Answer

For simple clarifications that do not impact MS-DRG assignment.

Question 6

A post-discharge review of a patient's chart reveals clinical indicators strongly suggestive of sepsis (fever, tachycardia, leukocytosis, positive blood cultures) which was treated with IV antibiotics, but a definitive diagnosis of sepsis was never documented. What is the appropriate action for the CDI professional?

Accepted Answer

Send a retrospective multiple-choice query to the attending physician with the relevant clinical indicators, offering 'sepsis' as an option along with others like 'bacteremia' or 'clinically unable to determine.'

Answer

Assume sepsis and recommend the coder add the diagnosis code.

Answer

Do not query, as the patient has already been discharged and the opportunity is missed.

Answer

Contact the physician and explain that failing to document sepsis will negatively affect the hospital's quality metrics.