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

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?

Accepted Answer

Case Mix Index (CMI)

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

Concurrent review

Answer

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:

Accepted Answer

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

Answer

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.

CIC - Certified Inpatient Coder Practice Test

CIC - Certified Inpatient Coder Practice Test

CIC CIC Clinical Documentation Improvement 2