CDIP Clinical Validation Principles 2

Question 1

A physician documents 'acute kidney injury' in a patient with a creatinine of 1.2 mg/dL (baseline 1.0). A CDI specialist reviews the record and finds no clinical indicators supporting AKI. What is the most appropriate action?

Accepted Answer

Query the physician to clarify if clinical indicators support the AKI diagnosis

Answer

Clinical validation requires querying the physician when documented diagnoses lack supporting clinical indicators, not unilaterally changing or ignoring documentation.

Question 2

Which organization's 'Coding Clinic' guidance is the authoritative source for ICD-10-CM/PCS coding advice that CDI specialists must follow?

Accepted Answer

American Hospital Association (AHA)

Answer

The AHA's Coding Clinic is the official publication providing authoritative ICD-10-CM/PCS coding guidance recognized by CMS.

Question 3

When performing clinical validation of a sepsis diagnosis, which set of criteria is most commonly referenced to determine clinical support?

Accepted Answer

SOFA/qSOFA and Sepsis-3 definitions

Answer

The Sepsis-3 consensus definitions using SOFA and qSOFA scores are the current standard for clinically validating sepsis diagnoses.

Question 4

A CDI specialist disagrees with a physician's documented diagnosis based on clinical indicators. After querying, the physician affirms the diagnosis. What should the CDI specialist do?

Accepted Answer

Accept the physician's clinical judgment and document the query outcome

Answer

Physicians hold final clinical authority; CDI specialists must respect physician judgment after a query and cannot unilaterally override documented diagnoses.

Question 5

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

Accepted Answer

Signs, symptoms, lab results, imaging, and treatment that collectively support a diagnosis

Answer

Clinical criteria encompass the full spectrum of objective and subjective findings—labs, vitals, imaging, symptoms, and treatment—that together support or refute a documented diagnosis.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Clinical Validation Principles 2