CDIP Quality Improvement and Compliance 3 — Questions and Answers
Question 1: When conducting a focused clinical documentation audit, which sampling methodology provides the most statistically valid results?
- Convenience sampling of the most recent 10 records
- Random sampling with an appropriate confidence interval (Correct answer)
- Targeted sampling of only high-cost DRGs
- Sampling only records with query activity
Correct answer: Random sampling with an appropriate confidence interval
Random sampling with an appropriate confidence interval ensures results are statistically representative of the entire population.
Question 2: A hospital receives a Medicare Recovery Audit Contractor (RAC) demand letter for overpayment. What is the first step in the appeals process?
- File a complaint with the OIG
- Request a redetermination from the Medicare Administrative Contractor (Correct answer)
- Submit an appeal directly to the federal district court
- Contact CMS to request a waiver of overpayment
Correct answer: Request a redetermination from the Medicare Administrative Contractor
The first level of the Medicare appeals process is a redetermination request submitted to the Medicare Administrative Contractor within 120 days.
Question 3: Which condition requires documentation of the relationship between two diagnoses before a combination code can be used?
- Hypertensive heart disease
- Type 2 diabetes with diabetic chronic kidney disease
- Sepsis due to pneumonia
- All of the above (Correct answer)
Correct answer: All of the above
Combination codes for hypertensive heart disease, diabetic CKD, and sepsis with a localized infection all require physician documentation of the causal relationship.
Question 4: A CDI program's case-mix index has declined over three consecutive quarters despite stable patient acuity. Which action should the CDI manager take first?
- Increase the number of queries issued per case
- Analyze query concurrence rates and denial patterns by DRG (Correct answer)
- Hire additional CDI specialists immediately
- Switch to a retrospective-only CDI review model
Correct answer: Analyze query concurrence rates and denial patterns by DRG
Analyzing query concurrence rates and denial patterns identifies whether the CMI decline is due to documentation gaps, coding issues, or payer denials.
Question 5: Under HIPAA, a CDI specialist reviewing records for quality improvement purposes must ensure that access is limited to:
- Records of patients who have signed a release form
- The minimum necessary information to accomplish the task (Correct answer)
- Records that are more than 30 days old
- Only records assigned to their specific physician group
Correct answer: The minimum necessary information to accomplish the task
HIPAA's minimum necessary standard requires that access to PHI be limited to what is reasonably necessary to accomplish the intended purpose.
Question 6: Which documentation element is essential for coding malnutrition in a hospitalized patient to the highest specificity?
- Body mass index less than 18.5
- Physician documentation of the type and severity of malnutrition (Correct answer)
- Dietitian assessment noting inadequate caloric intake
- Lab values showing low albumin and prealbumin
Correct answer: Physician documentation of the type and severity of malnutrition
ICD-10-CM requires physician documentation of the type (protein-calorie) and severity (mild, moderate, severe) to code malnutrition to the highest specificity.
Question 7: A CDI team is implementing a new concurrent review workflow. Which performance indicator would best demonstrate early program success?
- Reduction in average length of stay within 30 days
- Increase in query response rate from 60% to 85% within 90 days (Correct answer)
- Elimination of all coding-related denials within 60 days
- Achieving a case-mix index above the national average within 45 days
Correct answer: Increase in query response rate from 60% to 85% within 90 days
Increasing query response rate is an achievable short-term indicator that reflects physician engagement and program adoption.
CDIP Quality Improvement and Compliance 3
When conducting a focused clinical documentation audit, which sampling methodology provides the most statistically valid results?