CDIP Documentation Integrity and Data Quality 5 — Questions and Answers
Question 1: A CDI audit reveals that a complication of care was documented and coded but the physician's note only states 'patient developed fever post-op — likely viral.' What should occur?
- Retain the complication code since a fever was documented
- Query the physician to clarify whether the fever represents a complication or an unrelated condition (Correct answer)
- Remove the complication code and assign only fever
- Report the coder to the compliance officer
Correct answer: Query the physician to clarify whether the fever represents a complication or an unrelated condition
The physician's qualifier 'likely viral' suggests the fever may not be a complication; a query is needed to establish the clinical basis before assigning a complication code.
Question 2: Which of the following is an example of a 'leading query' that violates AHIMA and ACDIS query practice guidelines?
- 'Can you clarify the type of heart failure documented?'
- 'Based on the lab values, does the patient have acute kidney injury?' (Correct answer)
- 'Please specify whether the pneumonia is community-acquired or hospital-acquired.'
- 'Can you confirm or clarify the principal diagnosis for this admission?'
Correct answer: 'Based on the lab values, does the patient have acute kidney injury?'
A leading query suggests an answer by pointing to specific clinical indicators, which can bias the physician's response and compromise documentation integrity.
Question 3: When evaluating data quality, 'granularity' refers to:
- The frequency with which data is updated
- The level of detail at which data is recorded (Correct answer)
- The consistency of data across multiple records
- The accessibility of data to authorized users
Correct answer: The level of detail at which data is recorded
Granularity describes the level of specificity or detail captured in a data element, such as documenting 'type 2 diabetes with diabetic chronic kidney disease stage 3' rather than just 'diabetes.'
Question 4: A CDI specialist is conducting a retrospective record review. Which of the following is a key difference between retrospective and concurrent review?
- Retrospective review allows for physician queries before discharge
- Retrospective review occurs after the patient has been discharged and the record is complete (Correct answer)
- Retrospective review is performed only by coders, not CDI specialists
- Retrospective review is used exclusively for outpatient records
Correct answer: Retrospective review occurs after the patient has been discharged and the record is complete
Retrospective review takes place after the patient is discharged and the record is finalized, whereas concurrent review occurs while the patient is still admitted.
Question 5: Which of the following best describes 'data integrity' in a health information management context?
- The ability to store large volumes of health data securely
- The assurance that data is accurate, complete, consistent, and unaltered (Correct answer)
- The process of encrypting patient data for transmission
- The timeliness with which data is entered into the EHR
Correct answer: The assurance that data is accurate, complete, consistent, and unaltered
Data integrity means that health information is trustworthy — accurate, complete, consistent, and protected from unauthorized alteration throughout its lifecycle.
Question 6: A physician documents 'possible urinary tract infection' at the time of inpatient discharge. According to ICD-10-CM Official Guidelines for inpatient coding, how should this be coded?
- Code only the signs and symptoms (dysuria, frequency)
- Code the UTI as if confirmed, per inpatient uncertain diagnosis guidelines (Correct answer)
- Query the physician before any coding can occur
- Code as 'encounter for observation' since the diagnosis is uncertain
Correct answer: Code the UTI as if confirmed, per inpatient uncertain diagnosis guidelines
ICD-10-CM inpatient guidelines instruct coders to code uncertain diagnoses documented at discharge (such as 'possible,' 'probable,' or 'suspected') as if confirmed.
Question 7: Which tool or process is most effective for identifying systemic documentation gaps across a facility's entire inpatient population?
- Individual physician feedback sessions
- Focused retrospective coding audits on a random sample of records
- Real-time CDI concurrent review workflow with aggregate reporting (Correct answer)
- Peer-to-peer physician education without data tracking
Correct answer: Real-time CDI concurrent review workflow with aggregate reporting
Concurrent CDI review with aggregate reporting identifies documentation gaps in real time across the full patient population and generates data to drive systemic improvement.
CDIP Documentation Integrity and Data Quality 5
A CDI audit reveals that a complication of care was documented and coded but the physician's note only states 'patient developed fever post-op — likely viral.' What should occur?