CDIP Physician Query Process 3 — Questions and Answers
Question 1: According to AHIMA and ACDIS guidelines, a compliant query must always:
- Include the suggested ICD-10-CM code for the condition
- Be based on clinical indicators present in the medical record (Correct answer)
- Be approved by the compliance department before sending
- Reference the expected DRG impact
Correct answer: Be based on clinical indicators present in the medical record
All compliant queries must be grounded in clinical indicators documented in the medical record to avoid being considered leading or speculative.
Question 2: Which of the following query formats is generally considered most compliant by AHIMA?
- Open-ended query (Correct answer)
- Yes/no query
- Leading query
- Presumptive query
Correct answer: Open-ended query
Open-ended queries allow the physician to respond freely without being directed toward a specific answer, making them the most compliant format.
Question 3: A CDI specialist sends a query about malnutrition. The physician responds 'unable to determine.' How should this be coded?
- Code malnutrition based on clinical indicators
- Do not code malnutrition; use the physician's documented response (Correct answer)
- Escalate to the CMO for a final determination
- Assign the highest-severity malnutrition code
Correct answer: Do not code malnutrition; use the physician's documented response
The physician's documented response of 'unable to determine' is a valid clinical response that should be respected in coding.
Question 4: Which of the following is an indicator that a query may be inappropriate or non-compliant?
- The query lists multiple clinically supported diagnoses
- The query was sent during the patient's hospitalization
- The query was generated solely to increase reimbursement without clinical support (Correct answer)
- The query includes the patient's current lab values as context
Correct answer: The query was generated solely to increase reimbursement without clinical support
Queries generated only to improve reimbursement without corresponding clinical evidence are non-compliant and potentially fraudulent.
Question 5: What is the CDI specialist's role after a physician responds to a query?
- Ignore the response if it does not improve the DRG
- Communicate the response to the coding staff and ensure it is incorporated into coding (Correct answer)
- File the query without sharing with coders
- Requery if the response does not match expected documentation
Correct answer: Communicate the response to the coding staff and ensure it is incorporated into coding
The CDI specialist must share the physician's response with coding staff to ensure accurate code assignment reflects the updated documentation.
Question 6: Physician queries related to principal diagnosis clarification are most critical because:
- They affect only the SOI/ROM scores
- The principal diagnosis drives DRG assignment and reimbursement under MS-DRG methodology (Correct answer)
- They are required by CMS for all inpatient claims
- They eliminate the need for a discharge summary
Correct answer: The principal diagnosis drives DRG assignment and reimbursement under MS-DRG methodology
Under MS-DRG methodology, the principal diagnosis is the key driver of DRG assignment, making its accuracy essential for appropriate reimbursement.
Question 7: Which of the following best describes a 'yes/no' query format?
- A query presenting four diagnosis choices for the physician to select
- A query asking the physician to confirm or deny a specific condition (Correct answer)
- A query requesting the physician to write an addendum
- A query used only for complications of care
Correct answer: A query asking the physician to confirm or deny a specific condition
Yes/no queries ask the physician to confirm or deny a single condition and are considered acceptable when the clinical indicators clearly support that one condition.
CDIP Physician Query Process 3
According to AHIMA and ACDIS guidelines, a compliant query must always: