CDIP Record Review and Clarification 2

Question 1

A CDI specialist reviews a record where the attending documents 'sepsis' but the blood cultures are negative and antibiotics were discontinued after 48 hours. What is the most appropriate action?

Accepted Answer

Query the physician asking whether sepsis or an alternative diagnosis better reflects the clinical picture

Answer

Accept the diagnosis as documented without query

Answer

Change the diagnosis to 'suspected infection' in the coding system

Answer

Escalate to the compliance department immediately

Question 2

Which type of query format presents a list of diagnosis options based on clinical indicators and asks the physician to select, add, or indicate 'none of the above'?

Accepted Answer

Multiple-choice query

Answer

Open-ended query

Answer

Leading query

Answer

Verbal-only query

Question 3

A query is sent regarding a patient with a BMI of 42 and documentation of 'overweight.' The physician does not respond. How should the CDI specialist proceed?

Accepted Answer

Leave the query open and follow up per facility policy

Answer

Code obesity based on the BMI value alone

Answer

Close the query and code 'overweight' as documented

Answer

Request that the coder make the change without physician input

Question 4

During concurrent review, a CDI specialist notes a patient is receiving IV insulin drip and frequent glucose checks but 'diabetes' is not documented. What is the best approach?

Accepted Answer

Query the physician to clarify whether a diabetic condition exists

Answer

Code type 2 diabetes based on the treatment

Answer

Wait until discharge to review the record

Answer

Document diabetes in the clinical data field of the encoder

Question 5

Which statement best describes a 'leading' query and why it is non-compliant?

Accepted Answer

It suggests a specific diagnosis without adequate clinical basis, influencing the physician's response inappropriately

Answer

It offers multiple clinical options and is compliant

Answer

It is sent verbally and lacks a written record

Answer

It is compliant if the physician agrees with the suggestion

Question 6

A patient's record documents 'acute renal failure' on admission but the final diagnoses list only 'chronic kidney disease stage 3.' What should the CDI specialist do?

Accepted Answer

Query the physician to clarify whether acute-on-chronic kidney disease or AKF resolved should be documented

Answer

Code only chronic kidney disease as it is the final diagnosis

Answer

Add acute renal failure to the problem list independently

Answer

Ignore the discrepancy since the final diagnoses govern coding

Question 7

Post-discharge retrospective queries are considered appropriate in which scenario?

Accepted Answer

When a clinical indicator was present during the stay but the opportunity was missed during concurrent review

Answer

Whenever the CDI specialist wants a higher-weighted DRG

Answer

When the physician's original documentation was clear and complete

Answer

Only when the patient is readmitted within 30 days