CDIP Physician Query Process 4

Question 1

A query is sent to clarify whether a patient's respiratory failure is acute, chronic, or acute-on-chronic. This is an example of what type of query opportunity?

Accepted Answer

Specificity clarification

Answer

Asking the physician to specify the acuity of a condition (acute vs. chronic vs. acute-on-chronic) is a specificity clarification query.

Question 2

Which of the following clinical scenarios would most likely trigger a query for 'sepsis'?

Accepted Answer

Patient has tachycardia, fever, elevated WBC, and is on broad-spectrum IV antibiotics for pneumonia

Answer

Systemic signs such as tachycardia, fever, leukocytosis, and IV antibiotic use for a documented infection suggest sepsis, warranting a query.

Question 3

When querying for a complication of care, the CDI specialist must ensure that:

Accepted Answer

Clinical documentation supports a potential relationship between a procedure and the complication

Answer

Queries for complications of care must be supported by clinical indicators suggesting a procedural relationship before being sent.

Question 4

A physician responds to a query by writing a late entry addendum to the medical record. This response is considered:

Accepted Answer

Acceptable as long as the addendum is dated, timed, and authenticated per facility policy

Answer

Physician addenda are a valid and acceptable way to respond to queries as long as they follow proper documentation standards including date, time, and signature.

Question 5

What does the term 'query rate' measure in a CDI program?

Accepted Answer

The number of queries sent divided by the number of cases reviewed

Answer

Query rate is calculated as the number of queries sent relative to cases reviewed and is used to monitor CDI program activity.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Physician Query Process 4