CDIP Record Review and Clarification 4

Question 1

Which of the following is a key metric used to evaluate CDI program effectiveness related to record review?

Accepted Answer

Case Mix Index (CMI) before and after CDI intervention

Answer

Number of queries sent regardless of response rate

Answer

Total number of discharge records reviewed per quarter

Answer

Percentage of electronic health records with physician signatures

Question 2

A CDI specialist queries for 'malnutrition' based on low albumin alone. The physician disagrees. What is the most appropriate next step?

Accepted Answer

Accept the physician's response and close the query with the physician's documented conclusion

Answer

Escalate to the coding director to override the physician

Answer

Re-query using the same clinical indicators

Answer

Code malnutrition based on the lab value as a default

Question 3

When reviewing a record for encephalopathy, which clinical indicators would best support querying for a more specific type?

Accepted Answer

Altered mental status, EEG findings, metabolic abnormalities, or medication toxicity levels

Answer

Normal neurological exam findings only

Answer

Only the presence of a psychiatric diagnosis

Answer

A low sodium level alone without other findings

Question 4

A CDI specialist reviews a record in which the patient received a blood transfusion but 'anemia' is not documented. What is the best course of action?

Accepted Answer

Query the physician to clarify if an anemia diagnosis is present and its type

Answer

Code anemia based on the transfusion order

Answer

Document anemia in the nursing notes as a clinical finding

Answer

Ignore the gap since transfusions are routine procedures

Question 5

How does the 'Present on Admission' (POA) indicator affect CDI record review?

Accepted Answer

It determines whether a condition was present at admission, affecting HAC designation and payment

Answer

It has no impact on documentation or reimbursement

Answer

It only applies to outpatient records

Answer

It is assigned by the CDI specialist, not the physician

Question 6

Which scenario represents an appropriate use of a verbal query with required follow-up documentation?

Accepted Answer

Discussing a documentation gap verbally during rounds and then following up with a written query per facility policy

Answer

Sending a verbal query as a substitute for a written query to avoid a paper trail

Answer

Relaying the verbal response directly to the coder without physician documentation

Answer

Using verbal queries exclusively for high-severity diagnoses to speed the process

Question 7

A record shows a patient with a GFR of 28 and creatinine of 3.1, but only 'renal insufficiency' is documented. Which query approach best addresses this gap?

Accepted Answer

Query the physician with the GFR value to clarify if CKD staging should be specified in the documentation

Answer

Code CKD stage 3 based on the GFR without a query

Answer

Accept 'renal insufficiency' as a complete and specific diagnosis

Answer

Query only if the patient has dialysis orders