CIC CIC Clinical Documentation Improvement 2

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?

Accepted Answer

Query the physician to clarify the underlying cause, such as encephalopathy or delirium

Answer

Accept the documentation as-is

Answer

Code only unspecified altered mental status

Answer

Discharge the patient without further review

Question 2

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

Accepted Answer

Case Mix Index (CMI)

Answer

Number of nursing shifts per week

Answer

Patient satisfaction scores only

Answer

Number of dietary consultations

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?

Accepted Answer

Apply the combination code guideline linking diabetic CKD when both conditions are documented

Answer

Code only the condition that was treated first

Answer

Code only whichever diagnosis has the higher DRG weight

Answer

Query for confirmation before coding either condition

Question 4

What is the term for the process where a CDI specialist reviews records concurrently while the patient is still admitted?

Accepted Answer

Concurrent review

Answer

Retrospective review

Answer

Prospective billing

Answer

Post-discharge audit

Question 5

A patient is admitted with chest pain and ultimately diagnosed with NSTEMI. The coder should assign NSTEMI as the:

Accepted Answer

Principal diagnosis, as the condition established after study to be chiefly responsible for admission

Answer

Secondary diagnosis only

Answer

A symptom code since NSTEMI was not present on admission

Answer

An external cause code

Question 6

Which of the following best describes an 'encoder' in the context of inpatient coding?

Accepted Answer

A computer-assisted coding tool that helps coders assign ICD-10-CM/PCS and CPT codes

Answer

A software device used to encrypt patient data

Answer

A physician who documents in electronic health records

Answer

A compliance officer reviewing denied claims