CDIP Clinical Knowledge and Documentation Guidelines 2

Question 1

When a patient is admitted with decompensated heart failure and also has stage 3 chronic kidney disease, how should the CDI specialist approach querying for a relationship between the two conditions?

Accepted Answer

Query the physician if clinical indicators suggest a pathophysiological relationship even without explicit documentation

Answer

CDI specialists should query when clinical indicators support a pathophysiological relationship, as the physician must establish and document any causal link.

Question 2

Which of the following best describes 'clinical validation' in the context of CDI?

Accepted Answer

Verifying that documented diagnoses are supported by clinical evidence in the medical record

Answer

Clinical validation confirms that diagnoses documented by the physician are substantiated by objective clinical findings, lab values, and other evidence.

Question 3

A patient's lab results show a serum lactate of 4.2 mmol/L and blood cultures are positive. The physician documents 'sepsis.' What additional documentation query may be appropriate?

Accepted Answer

Query to clarify whether septic shock or organ dysfunction is present given the lactate elevation

Answer

An elevated lactate ≥2 mmol/L with sepsis may indicate septic shock per Sepsis-3 criteria, warranting a query for clarification.

Question 4

Under ICD-10-CM guidelines, when two or more diagnoses equally meet the definition of principal diagnosis, what should guide final code selection?

Accepted Answer

Either condition may be sequenced first, guided by the attending physician's preference or coding guidelines

Answer

When two conditions equally qualify as principal diagnosis, ICD-10-CM guidelines allow either to be sequenced first, and physician or coder judgment applies.

Question 5

A patient is admitted for a hip fracture following a mechanical fall. Which documentation element is most critical for accurate coding of the fracture?

Accepted Answer

Laterality, fracture type, and whether it is an initial encounter, subsequent, or sequela

Answer

ICD-10-CM fracture codes require specificity including laterality, fracture type, and encounter type (initial, subsequent, or sequela).

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Clinical Knowledge and Documentation Guidelines 2