CIC CIC Clinical Documentation Improvement 2 — Questions and Answers
Question 1: A physician documents 'altered mental status' as the principal diagnosis for an admitted patient. What action should a CDI specialist most likely take?
- Accept the documentation as-is
- Query the physician to clarify the underlying cause, such as encephalopathy or delirium (Correct answer)
- Code only unspecified altered mental status
- Discharge the patient without further review
Correct answer: Query the physician to clarify the underlying cause, such as encephalopathy or delirium
Altered mental status is a symptom, not a specific diagnosis, and CDI specialists should query for the underlying etiology to support more specific and accurate coding.
Question 2: Which of the following is a key metric used to evaluate the effectiveness of a CDI program?
- Number of nursing shifts per week
- Case Mix Index (CMI) (Correct answer)
- Patient satisfaction scores only
- Number of dietary consultations
Correct answer: Case Mix Index (CMI)
Case Mix Index (CMI) reflects the average relative weight of DRGs and is a primary indicator of CDI program effectiveness, as higher CMI generally reflects more accurate documentation of patient acuity.
Question 3: When a CDI specialist identifies that a patient has both chronic kidney disease (CKD) stage 3 and type 2 diabetes, which coding guideline is most relevant?
- Code only the condition that was treated first
- Apply the combination code guideline linking diabetic CKD when both conditions are documented (Correct answer)
- Code only whichever diagnosis has the higher DRG weight
- Query for confirmation before coding either condition
Correct answer: Apply the combination code guideline linking diabetic CKD when both conditions are documented
ICD-10-CM has a combination code (E11.22) for type 2 diabetes with diabetic chronic kidney disease, and per coding guidelines, the assumed causal relationship between diabetes and CKD should be coded as linked.
Question 4: What is the term for the process where a CDI specialist reviews records concurrently while the patient is still admitted?
- Retrospective review
- Prospective billing
- Concurrent review (Correct answer)
- Post-discharge audit
Correct answer: Concurrent review
Concurrent review occurs while the patient is still in the hospital, allowing CDI specialists to query physicians and clarify documentation before discharge.
Question 5: A patient is admitted with chest pain and ultimately diagnosed with NSTEMI. The coder should assign NSTEMI as the:
- Secondary diagnosis only
- Principal diagnosis, as the condition established after study to be chiefly responsible for admission (Correct answer)
- A symptom code since NSTEMI was not present on admission
- An external cause code
Correct answer: Principal diagnosis, as the condition established after study to be chiefly responsible for admission
Per UHDDS guidelines, the principal diagnosis is the condition established after study to be chiefly responsible for the admission, making NSTEMI the principal diagnosis in this scenario.
Question 6: Which of the following best describes an 'encoder' in the context of inpatient coding?
- A software device used to encrypt patient data
- A computer-assisted coding tool that helps coders assign ICD-10-CM/PCS and CPT codes (Correct answer)
- A physician who documents in electronic health records
- A compliance officer reviewing denied claims
Correct answer: A computer-assisted coding tool that helps coders assign ICD-10-CM/PCS and CPT codes
An encoder is a software tool that assists coders in navigating code books and assigning accurate ICD-10-CM, ICD-10-PCS, and MS-DRG codes.
CIC CIC Clinical Documentation Improvement 2
A physician documents 'altered mental status' as the principal diagnosis for an admitted patient.
What action should a CDI specialist most likely take?