CDIP Clinical Knowledge and Documentation Guidelines 3 — Questions and Answers
Question 1: A CDI specialist identifies that a patient's eGFR dropped from 62 to 28 mL/min/1.73m² during hospitalization after IV contrast administration. What query is most appropriate?
- Query for acute tubular necrosis as the contrast effect is always ATN
- Query to clarify whether contrast-induced nephropathy or acute kidney injury is present and if so, the severity (Correct answer)
- No query is needed since the eGFR will return to baseline
- Query for end-stage renal disease given the low eGFR
Correct answer: Query to clarify whether contrast-induced nephropathy or acute kidney injury is present and if so, the severity
A significant acute eGFR decline post-contrast warrants a query for AKI or contrast-induced nephropathy with stage clarification.
Question 2: Which condition is NOT included in the CMS list of Hospital-Acquired Conditions (HACs) relevant to CDI review?
- Catheter-associated urinary tract infection (CAUTI)
- Central line-associated bloodstream infection (CLABSI)
- Ventilator-associated pneumonia (VAP)
- Community-acquired pneumonia present on admission (Correct answer)
Correct answer: Community-acquired pneumonia present on admission
Community-acquired pneumonia present on admission is not an HAC; HACs are conditions not present on admission that occur during the hospital stay.
Question 3: What is the significance of the Present on Admission (POA) indicator for CDI specialists?
- It only affects coding of surgical complications
- It determines whether a condition was present at admission, affecting HAC payment penalties and quality metrics (Correct answer)
- It is required only for Medicare patients over age 65
- It is used to identify which physician should be queried first
Correct answer: It determines whether a condition was present at admission, affecting HAC payment penalties and quality metrics
The POA indicator determines if a condition existed at admission and directly impacts HAC-related payment adjustments and quality reporting.
Question 4: Under Sepsis-3 definitions, which of the following best characterizes 'organ dysfunction' in the context of sepsis documentation?
- Any elevation of white blood cell count above normal
- An acute change in SOFA score of ≥2 points attributable to infection (Correct answer)
- Positive blood cultures with fever above 38.5°C
- A single elevated creatinine value without baseline comparison
Correct answer: An acute change in SOFA score of ≥2 points attributable to infection
Sepsis-3 defines organ dysfunction as an acute change in total SOFA score ≥2 points due to infection, reflecting life-threatening organ failure.
Question 5: A physician documents 'possible aspiration pneumonitis vs. aspiration pneumonia' at discharge. How should this be coded per ICD-10-CM guidelines for inpatient settings?
- Code only the signs and symptoms since the diagnosis is uncertain
- Code the condition that generated the most charges during the stay
- Code aspiration pneumonitis as the principal diagnosis since it was listed first
- Code either condition as if confirmed, following inpatient uncertain diagnosis guidelines (Correct answer)
Correct answer: Code either condition as if confirmed, following inpatient uncertain diagnosis guidelines
ICD-10-CM inpatient guidelines allow coding of 'possible,' 'probable,' or 'suspected' conditions at discharge as if confirmed.
Question 6: Which of the following best supports documentation of 'protein-calorie malnutrition' severe enough to affect DRG assignment?
- Patient refuses hospital meals on one occasion
- BMI of 22 with no weight loss documented
- 25% unintentional weight loss over 6 months with severe muscle wasting documented by dietitian and confirmed by physician (Correct answer)
- Patient requesting dietary counseling at discharge
Correct answer: 25% unintentional weight loss over 6 months with severe muscle wasting documented by dietitian and confirmed by physician
Severe malnutrition requires documentation of significant weight loss, muscle wasting, and reduced intake, confirmed by the treating physician.
Question 7: When documenting pressure injuries for optimal coding specificity, which staging classification system is primarily referenced in ICD-10-CM?
- Braden Scale risk stratification
- National Pressure Injury Advisory Panel (NPIAP) staging (Stage 1 through 4, unstageable, deep tissue) (Correct answer)
- Wagner grading system for diabetic foot ulcers
- Fontaine classification for peripheral arterial disease
Correct answer: National Pressure Injury Advisory Panel (NPIAP) staging (Stage 1 through 4, unstageable, deep tissue)
ICD-10-CM pressure injury codes align with NPIAP staging, requiring documentation of specific stage for accurate code assignment.
CDIP Clinical Knowledge and Documentation Guidelines 3
A CDI specialist identifies that a patient's eGFR dropped from 62 to 28 mL/min/1.73m² during hospitalization after IV contrast administration.
What query is most appropriate?