CDIP Quality Improvement and Compliance 5

Question 1

A CDI program wants to reduce the time from patient admission to initial CDI review. Which workflow change would most directly achieve this goal?

Accepted Answer

Adopting a concurrent 24-hour review target with electronic worklist prioritization

Answer

Concurrent review with a 24-hour target and electronic worklist prioritization ensures timely intervention while the patient is still admitted.

Question 2

Which ICD-10-CM guideline governs the sequencing of a condition that develops as a complication of a procedure?

Accepted Answer

Guideline I.C.19.g for complications of care

Answer

ICD-10-CM guideline I.C.19.g provides specific instructions for coding and sequencing complications of surgical and medical care.

Question 3

A hospital is preparing for a Joint Commission survey. Which CDI-related documentation standard is most likely to be evaluated?

Accepted Answer

Timeliness and completeness of medical record entries including discharge summaries

Answer

The Joint Commission evaluates medical record completion standards including timeliness of discharge summaries and authentication of entries.

Question 4

A CDI specialist identifies a patient with chronic kidney disease stage 3 and type 2 diabetes. The physician has not linked them. What is the correct approach?

Accepted Answer

Query the physician to determine if the CKD is due to diabetes

Answer

ICD-10-CM requires physician documentation of the causal relationship between diabetes and CKD before the combination code can be used.

Question 5

Which approach is most consistent with an effective CDI compliance program when a physician consistently disagrees with CDI query suggestions?

Accepted Answer

Document the physician's response and code based on their documented clinical judgment

Answer

When a physician responds to a query and disagrees, the coder must code based on the physician's documented clinical judgment, as only the physician can establish the diagnosis.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Quality Improvement and Compliance 5