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

CMI tracks the average resource intensity of inpatient cases and is a primary benchmark for evaluating CDI impact on documentation accuracy.

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

The physician's clinical judgment is final; CDI specialists facilitate documentation clarity but cannot override provider decisions.

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

Multiple clinical indicators such as altered mental status, abnormal EEG, or metabolic derangements help support a query for a specific encephalopathy type.

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

A blood transfusion is a significant clinical indicator that may support a query for anemia, allowing the physician to document and specify the condition.

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

POA status affects CMS Hospital-Acquired Condition policy, which can impact payment and quality reporting for conditions that develop during hospitalization.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Record Review and Clarification 4