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

'Urosepsis' is not a valid ICD-10-CM indexed term; a query should clarify whether the physician means UTI, sepsis due to UTI, or another condition.

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

Compliant queries must include the clinical indicators that prompted the question, providing the physician with objective evidence to inform their response.

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

Queries driven solely by DRG optimization rather than documentation accuracy constitute non-compliant, potentially fraudulent behavior under AHIMA and ACDIS guidelines.

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

ICD-10-CM has distinct codes for systolic/diastolic and acute/chronic/combined CHF, which affect MS-DRG grouping and quality metrics.

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 address clinical documentation gaps for accuracy and completeness, while coding queries address specific ICD-10-CM/PCS convention or sequencing questions.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Record Review and Clarification 5