CDIP Record Review and Clarification 3

Question 1

Which organization's guidelines define compliant query practices for CDI professionals?

Accepted Answer

AHIMA and ACDIS joint query practice brief

Answer

The American Medical Association (AMA)

Answer

The Centers for Medicare & Medicaid Services (CMS) alone

Answer

The Joint Commission accreditation standards

Question 2

A physician documents 'possible pneumonia' at discharge. Under UHDDS guidelines for inpatient coding, how should this be handled?

Accepted Answer

Code 'possible pneumonia' as if confirmed, since uncertain diagnoses are coded as confirmed for inpatient encounters

Answer

Code it as 'signs and symptoms' since it is unconfirmed

Answer

Query the physician to obtain a definitive diagnosis before coding

Answer

Code only the symptoms such as fever and cough

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?

Accepted Answer

Query whether the patient had an acute myocardial infarction or another cardiac diagnosis

Answer

Accept 'chest pain' since the physician did not document a cardiac event

Answer

Code NSTEMI based on the lab values without a query

Answer

Document 'rule out MI' independently in the clinical documentation

Question 4

Which of the following best describes the principal diagnosis for inpatient coding?

Accepted Answer

The condition established after study to be chiefly responsible for the admission

Answer

The condition with the highest severity of illness score

Answer

The first condition listed on the discharge summary

Answer

The diagnosis that generates the highest MS-DRG weight

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?

Accepted Answer

Query the physician to clarify the organism in the final discharge diagnosis

Answer

Code MRSA based on the progress note since it is more specific

Answer

Code both diagnoses to capture the most complete picture

Answer

Disregard the progress note and use only the discharge summary

Question 6

What is the purpose of a 'clinical validation' query in CDI practice?

Accepted Answer

To verify that clinical evidence in the record supports a diagnosis the physician has already documented

Answer

To ensure the patient's insurance will cover the documented diagnosis

Answer

To request a higher-severity diagnosis to improve reimbursement

Answer

To confirm that the coding team agrees with the physician's diagnosis

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?

Accepted Answer

Hospital-Acquired Condition (HAC)

Answer

Principal diagnosis

Answer

Present on Admission (POA) exempt condition

Answer

Complication excluded from MS-DRG calculation