CDIP Clinical Knowledge and Documentation Guidelines 5

Question 1

Which of the following scenarios best illustrates the concept of 'upcoding' that CDI specialists must avoid?

Accepted Answer

Assigning a higher-weighted diagnosis code that is not supported by clinical documentation or physician attestation

Answer

Upcoding involves assigning codes for conditions not clinically supported or documented, which is fraudulent and violates compliance standards.

Question 2

When a patient is on mechanical ventilation and the physician documents 'respiratory failure,' what additional specificity should CDI seek?

Accepted Answer

Whether the respiratory failure is acute, chronic, or acute-on-chronic, and whether it is hypoxic, hypercapnic, or unspecified

Answer

Respiratory failure specificity (acuity and type) affects ICD-10-CM code assignment and DRG severity, making it a key CDI query target.

Question 3

A physician documents 'UTI' in a patient with an indwelling Foley catheter inserted during the current hospitalization. What CDI consideration applies?

Accepted Answer

Consider querying whether this is a catheter-associated urinary tract infection (CAUTI), as it has HAC and quality implications

Answer

CAUTI is an HAC with payment and quality implications; CDI should query to clarify whether the UTI is catheter-associated.

Question 4

In the context of CDI, what is the primary purpose of a physician query?

Accepted Answer

To improve the accuracy and completeness of clinical documentation to reflect the true complexity of care provided

Answer

The fundamental goal of CDI queries is accurate, complete documentation that reflects the clinical picture — not simply revenue optimization.

Question 5

A patient is admitted with acute pancreatitis. The physician notes a history of alcohol use but does not document a causal relationship. What is the appropriate CDI action?

Accepted Answer

Query the physician to clarify if the pancreatitis is alcohol-induced, idiopathic, or due to another etiology

Answer

ICD-10-CM has distinct codes for alcohol-induced vs. other types of pancreatitis, and the physician must document the causal relationship for accurate coding.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Clinical Knowledge and Documentation Guidelines 5