CDIP Clinical Knowledge and Documentation Guidelines 3

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?

Accepted Answer

Query to clarify whether contrast-induced nephropathy or acute kidney injury is present and if so, the severity

Answer

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?

Accepted Answer

Community-acquired pneumonia present on admission

Answer

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?

Accepted Answer

It determines whether a condition was present at admission, affecting HAC payment penalties and quality metrics

Answer

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?

Accepted Answer

An acute change in SOFA score of ≥2 points attributable to infection

Answer

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?

Accepted Answer

Code either condition as if confirmed, following inpatient uncertain diagnosis guidelines

Answer

ICD-10-CM inpatient guidelines allow coding of 'possible,' 'probable,' or 'suspected' conditions at discharge as if confirmed.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Clinical Knowledge and Documentation Guidelines 3