CDIP Record Review and Clarification 5

Question 1

A CDI specialist encounters a record where 'urosepsis' is documented. What is the correct CDI response to this term?

Accepted Answer

Query the physician because 'urosepsis' is not an ICD-10-CM indexed term and may represent either a UTI or true sepsis

Answer

Code urosepsis as sepsis originating from a urinary source

Answer

Accept the documentation and default to a UTI code

Answer

Code both sepsis and UTI to cover all possibilities

Question 2

Which element is essential in every compliant physician query to ensure documentation integrity?

Accepted Answer

The clinical indicators from the record that prompted the query

Answer

A suggested diagnosis that matches the highest-weighted DRG

Answer

The coder's preferred diagnosis option listed first

Answer

A statement that the response will affect reimbursement

Question 3

During a retrospective review audit, a CDI manager discovers that a specialist routinely sends queries only to shift DRG weight upward. This practice is best described as:

Accepted Answer

Potentially fraudulent query behavior that violates AHIMA/ACDIS compliance guidelines

Answer

Effective CDI strategy aligned with hospital revenue goals

Answer

Acceptable if the physician agrees with all queries

Answer

Standard practice that mirrors industry benchmarks

Question 4

A patient has documented 'CHF exacerbation' but the specific type (systolic vs. diastolic, acute vs. chronic) is not specified. Why does this matter for CDI?

Accepted Answer

Specificity affects ICD-10-CM code assignment and may impact severity of illness, risk of mortality, and MS-DRG assignment

Answer

It does not matter; all CHF codes map to the same DRG

Answer

Only cardiologists are required to specify CHF type

Answer

The coder can select the type based on the echocardiogram report independently

Question 5

What is the primary difference between a CDI query and a coding query?

Accepted Answer

CDI queries focus on clinical documentation completeness; coding queries clarify specific coding conventions or sequencing

Answer

CDI queries are sent after discharge; coding queries are sent concurrently

Answer

CDI queries can only be sent by physicians; coding queries are sent by coders

Answer

There is no difference; both terms describe the same process

Question 6

A CDI specialist reviews a surgical record where the operative report documents a complication (hemorrhage requiring transfusion) but the discharge summary does not mention it. What should be done?

Accepted Answer

Query the physician to include the operative complication in the discharge summary for complete documentation

Answer

Code the hemorrhage from the operative report since it is physician-authored

Answer

Omit the complication since the discharge summary is the authoritative source

Answer

Have the surgeon amend the discharge summary without a formal query

Question 7

When reviewing a record for a patient with a documented stroke, which additional clarification is most valuable for accurate ICD-10-CM coding?

Accepted Answer

Whether the stroke is ischemic or hemorrhagic, the affected side, and the dominant or non-dominant laterality

Answer

The patient's insurance type and coverage level

Answer

Only the discharge disposition of the patient

Answer

The number of days the patient was in the ICU