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

The 2022 AHIMA/ACDIS 'Guidelines for Achieving a Compliant Query Practice' recommends using a multiple-choice format when multiple clinically reasonable options exist. This format allows the provider to use their clinical judgment to select the most appropriate diagnosis based on the presented clinical indicators (low EF, symptoms, treatment) without being led to a specific answer. Mentioning reimbursement is non-compliant, and a Yes/No query is inappropriate for establishing this level of specificity when the initial diagnosis is already documented.

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

A primary reason to initiate a query is to resolve conflicting, imprecise, incomplete, ambiguous, or inconsistent documentation within the health record. The goal is to ensure the final coded data accurately reflects the patient's condition and care, which requires a single, consistent diagnostic statement. The query should not be used to educate in a leading manner, be based on reimbursement, or favor one provider's documentation over another without clarification.

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

Compliant queries must be based on and cite the specific clinical indicators found within the patient's health record for that episode of care. This provides the clinical evidence for why clarification is needed. Mentioning the impact on reimbursement or quality scores is strictly prohibited as it is considered leading. A new diagnosis cannot be introduced via a yes/no query; this format is reserved for clarifying diagnoses already documented.

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

This option is an open-ended, non-leading question that presents the relevant clinical indicators (low hemoglobin, positive FOBT) and asks the provider to clarify the diagnosis using their clinical judgment. It does not direct the physician to a specific diagnosis, mention severity of illness impact, or improperly use a yes/no format. Referencing coding guidelines in a query is also considered inappropriate.

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

Verbal queries are appropriate for complex cases where multiple clarifications might be needed, allowing for a real-time discussion. However, all verbal queries that impact coding must be documented in the record with the date, time, participants, clinical indicators discussed, and the provider's response, which must then be authenticated by the provider in the permanent health record.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

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