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

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

Conflicting documentation between notes and the discharge summary warrants a clarifying query so the physician can confirm and reconcile the final diagnosis.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Record Review and Clarification 3