Record Review and Clarification 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 Record Review and Clarification flashcards as text
A CDI specialist encounters a record where 'urosepsis' is documented. What is the correct CDI response to this term?
Answer: Query the physician because 'urosepsis' is not an ICD-10-CM indexed term and may represent either a UTI or true sepsis
'Urosepsis' is not a valid ICD-10-CM indexed term; a query should clarify whether the physician means UTI, sepsis due to UTI, or another condition.
Which element is essential in every compliant physician query to ensure documentation integrity?
Answer: The clinical indicators from the record that prompted the query
Compliant queries must include the clinical indicators that prompted the question, providing the physician with objective evidence to inform their response.
During a retrospective review audit, a CDI manager discovers that a specialist routinely sends queries only to shift DRG weight upward. This practice is best described as:
Answer: Potentially fraudulent query behavior that violates AHIMA/ACDIS compliance guidelines
Queries driven solely by DRG optimization rather than documentation accuracy constitute non-compliant, potentially fraudulent behavior under AHIMA and ACDIS guidelines.
A patient has documented 'CHF exacerbation' but the specific type (systolic vs. diastolic, acute vs. chronic) is not specified. Why does this matter for CDI?
Answer: Specificity affects ICD-10-CM code assignment and may impact severity of illness, risk of mortality, and MS-DRG assignment
ICD-10-CM has distinct codes for systolic/diastolic and acute/chronic/combined CHF, which affect MS-DRG grouping and quality metrics.
What is the primary difference between a CDI query and a coding query?
Answer: CDI queries focus on clinical documentation completeness; coding queries clarify specific coding conventions or sequencing
CDI queries address clinical documentation gaps for accuracy and completeness, while coding queries address specific ICD-10-CM/PCS convention or sequencing questions.
A CDI specialist reviews a surgical record where the operative report documents a complication (hemorrhage requiring transfusion) but the discharge summary does not mention it. What should be done?
Answer: Query the physician to include the operative complication in the discharge summary for complete documentation
A compliant query asking the physician to address the operative complication in the discharge summary ensures all relevant diagnoses are captured in the final documentation.
When reviewing a record for a patient with a documented stroke, which additional clarification is most valuable for accurate ICD-10-CM coding?
Answer: Whether the stroke is ischemic or hemorrhagic, the affected side, and the dominant or non-dominant laterality
ICD-10-CM stroke coding requires type (ischemic vs. hemorrhagic), affected cerebral artery, laterality, and dominance for maximum specificity.