CDIP Quality Improvement and Compliance 2 — Questions and Answers
Question 1: A hospital's CDI team notices a pattern of sepsis cases documented without meeting Sepsis-3 criteria. Which quality improvement step should come first?
- Immediately correct all past sepsis codes
- Perform a root cause analysis to identify the documentation gap (Correct answer)
- Report the physicians to the compliance officer
- Suspend sepsis queries until criteria are clarified
Correct answer: Perform a root cause analysis to identify the documentation gap
Root cause analysis identifies the underlying documentation gap before implementing corrective actions.
Question 2: Under the OIG Work Plan, which documentation pattern is most likely to trigger a focused audit of inpatient records?
- Low CC/MCC capture rates
- High rates of principal diagnosis changes after query (Correct answer)
- Consistent use of 'probable' qualifier in diagnoses
- Frequent use of combination codes
Correct answer: High rates of principal diagnosis changes after query
High rates of principal diagnosis changes after query can signal inappropriate query practices and are an OIG audit trigger.
Question 3: A CDI specialist finds that a query was leading because it listed only DRG-favorable diagnoses. Which standard does this violate?
- UHDDS guidelines for principal diagnosis selection
- AHIMA's Standards of Ethical Coding
- The ACDIS/AHIMA query practice brief (Correct answer)
- CMS Conditions of Participation for medical staff
Correct answer: The ACDIS/AHIMA query practice brief
The ACDIS/AHIMA CDI query practice brief explicitly prohibits leading queries that suggest financially advantageous diagnoses.
Question 4: Which metric best measures CDI program effectiveness in improving specificity of documented diagnoses?
- Average length of stay
- CC/MCC capture rate (Correct answer)
- Coder query rate
- Discharge not final coded rate
Correct answer: CC/MCC capture rate
The CC/MCC capture rate directly reflects how often complications and comorbidities are documented with sufficient specificity.
Question 5: A quality review reveals coders are querying for conditions that clearly exist in the record without physician attestation. What is the most appropriate corrective action?
- Encourage the practice to improve case-mix index
- Stop all queries and re-train on query indications (Correct answer)
- Allow queries only for high-value DRG shifts
- Have CDI specialists pre-approve all coder queries
Correct answer: Stop all queries and re-train on query indications
Queries are only appropriate when documentation is unclear, incomplete, or conflicting—not for conditions already clearly documented.
Question 6: Which federal statute imposes civil monetary penalties for knowingly submitting false claims to Medicare or Medicaid?
- HIPAA Privacy Rule
- False Claims Act (Correct answer)
- Stark Law
- Anti-Kickback Statute
Correct answer: False Claims Act
The False Claims Act imposes civil penalties up to three times the amount of the false claim plus per-claim fines.
Question 7: A CDI program tracks 'query response rate' as a KPI. What does this metric measure?
- The percentage of queries resulting in a DRG change
- The percentage of issued queries that receive a physician response (Correct answer)
- The number of queries issued per 1,000 discharges
- The time elapsed between query issue and physician response
Correct answer: The percentage of issued queries that receive a physician response
Query response rate measures the proportion of queries that physicians answer, reflecting physician engagement with the CDI process.
CDIP Quality Improvement and Compliance 2
A hospital's CDI team notices a pattern of sepsis cases documented without meeting Sepsis-3 criteria.
Which quality improvement step should come first?