Quality Improvement and Compliance Flashcards
7 cards from real CDIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Improvement and Compliance flashcards as text
A CDI specialist reviews a record where the attending documents 'respiratory failure' but the pulmonologist documents 'acute hypoxic respiratory failure.' Which coding guideline applies?
Answer: Query the attending to clarify and reconcile the conflicting documentation
When provider documentation conflicts, a query is required to reconcile the discrepancy before a final diagnosis can be coded.
Which element is NOT required for a compliant CDI query according to ACDIS/AHIMA guidelines?
Answer: A statement of the financial impact of the query
Queries must never include financial impact information, as this constitutes a leading query designed to influence diagnosis selection for reimbursement.
A hospital's compliance audit reveals that 40% of HAC (Hospital-Acquired Condition) cases lack required 'present on admission' (POA) indicators. What is the primary risk?
Answer: Loss of Medicare payment for those HAC-related conditions
CMS does not pay the higher DRG rate for cases where a HAC occurs that was not present on admission, resulting in payment reduction.
Which of the following best describes the concept of 'clinical validation' in the CDI context?
Answer: Determining whether the clinical evidence supports the documented diagnosis
Clinical validation involves reviewing clinical evidence in the record to confirm that a documented diagnosis is clinically supported.
When a payer denies a claim for 'lack of medical necessity,' what documentation should the CDI specialist prioritize in the appeal?
Answer: Clinical documentation demonstrating the patient met criteria for the level of care
Medical necessity appeals require clinical documentation showing the patient's condition warranted the level of care that was provided.
A CDI specialist is reviewing a patient with a documented BMI of 41 and the attending has noted 'obesity.' What query opportunity exists?
Answer: Query to clarify whether the obesity is morbid obesity (Class III) to capture a more specific code
ICD-10-CM provides separate codes for morbid (Class III) obesity, and physician documentation of this specificity results in a more precise code.
Under the PEPPER (Program for Evaluating Payment Patterns Electronic Report), a hospital's pneumonia DRG is at the 80th percentile. What does this indicate?
Answer: The hospital's pneumonia billing pattern is higher than 80% of comparable hospitals, warranting review
A high PEPPER percentile for a DRG indicates the hospital's billing pattern is an outlier compared to peers, suggesting a need for internal review.