CDIP Record Review and Clarification 3 — Questions and Answers
Question 1: Which organization's guidelines define compliant query practices for CDI professionals?
- The American Medical Association (AMA)
- AHIMA and ACDIS joint query practice brief (Correct answer)
- The Centers for Medicare & Medicaid Services (CMS) alone
- The Joint Commission accreditation standards
Correct answer: AHIMA and ACDIS joint query practice brief
AHIMA and ACDIS jointly publish the query practice brief that defines compliant CDI query standards.
Question 2: A physician documents 'possible pneumonia' at discharge. Under UHDDS guidelines for inpatient coding, how should this be handled?
- Code it as 'signs and symptoms' since it is unconfirmed
- Code 'possible pneumonia' as if confirmed, since uncertain diagnoses are coded as confirmed for inpatient encounters (Correct answer)
- Query the physician to obtain a definitive diagnosis before coding
- Code only the symptoms such as fever and cough
Correct answer: Code 'possible pneumonia' as if confirmed, since uncertain diagnoses are coded as confirmed for inpatient encounters
UHDDS inpatient coding guidelines allow uncertain diagnoses (possible, probable, suspected) to be coded as if confirmed at the time of discharge.
Question 3: During record review, a CDI specialist finds a patient with a troponin of 2.8 ng/mL and an EKG showing ST changes, but only 'chest pain' is documented. What is the most appropriate query focus?
- Query whether the patient had an acute myocardial infarction or another cardiac diagnosis (Correct answer)
- Accept 'chest pain' since the physician did not document a cardiac event
- Code NSTEMI based on the lab values without a query
- Document 'rule out MI' independently in the clinical documentation
Correct answer: Query whether the patient had an acute myocardial infarction or another cardiac diagnosis
Clinical indicators such as elevated troponin and EKG changes support querying for a more specific cardiac diagnosis consistent with those findings.
Question 4: Which of the following best describes the principal diagnosis for inpatient coding?
- The condition with the highest severity of illness score
- The condition established after study to be chiefly responsible for the admission (Correct answer)
- The first condition listed on the discharge summary
- The diagnosis that generates the highest MS-DRG weight
Correct answer: The condition established after study to be chiefly responsible for the admission
Per UHDDS, the principal diagnosis is the condition determined after study to be chiefly responsible for occasioning the admission.
Question 5: A CDI specialist reviews a record where the physician documents 'MRSA infection' in a progress note but the discharge summary only lists 'staph infection.' How should this be addressed?
- Code MRSA based on the progress note since it is more specific
- Query the physician to clarify the organism in the final discharge diagnosis (Correct answer)
- Code both diagnoses to capture the most complete picture
- Disregard the progress note and use only the discharge summary
Correct answer: Query the physician to clarify the organism in the final discharge diagnosis
Conflicting documentation between notes and the discharge summary warrants a clarifying query so the physician can confirm and reconcile the final diagnosis.
Question 6: What is the purpose of a 'clinical validation' query in CDI practice?
- To ensure the patient's insurance will cover the documented diagnosis
- To verify that clinical evidence in the record supports a diagnosis the physician has already documented (Correct answer)
- To request a higher-severity diagnosis to improve reimbursement
- To confirm that the coding team agrees with the physician's diagnosis
Correct answer: To verify that clinical evidence in the record supports a diagnosis the physician has already documented
Clinical validation queries assess whether the documented diagnosis is supported by objective clinical evidence in the record, ensuring coding accuracy and integrity.
Question 7: A patient is admitted with a hip fracture and develops a hospital-acquired pressure injury during the stay. For CDI purposes, this pressure injury is classified as which type of condition?
- Principal diagnosis
- Present on Admission (POA) exempt condition
- Hospital-Acquired Condition (HAC) (Correct answer)
- Complication excluded from MS-DRG calculation
Correct answer: Hospital-Acquired Condition (HAC)
Hospital-acquired pressure injuries (stage 3 or 4) are CMS-designated Hospital-Acquired Conditions, affecting POA status reporting and payment.
CDIP Record Review and Clarification 3
Which organization's guidelines define compliant query practices for CDI professionals?