CIC CIC Clinical Documentation Improvement 3

Question 1

When a physician documents 'malnutrition' without further specification, what should a CDI specialist do to optimize coding accuracy?

Accepted Answer

Query the physician to clarify the type and severity of malnutrition (e.g., mild, moderate, severe)

Answer

Code protein-calorie malnutrition by default

Answer

Ignore the documentation as it rarely affects DRGs

Answer

Code it only if the dietitian also documents it

Question 2

What is the significance of the 'present on admission' (POA) indicator in inpatient coding?

Accepted Answer

It identifies whether a condition existed at the time of inpatient admission, affecting hospital-acquired condition reporting

Answer

It determines whether the patient needs surgery

Answer

It indicates whether the attending physician was present during admission

Answer

It determines how long the patient will stay

Question 3

A physician's discharge summary documents 'UTI' but lab results show E. coli bacteremia. What should the CDI specialist do?

Accepted Answer

Query the physician about whether the bacteremia should be documented and coded separately

Answer

Code only UTI as documented

Answer

Code E. coli bacteremia without querying

Answer

Disregard the lab results since only the summary matters

Question 4

Which of the following best describes a 'retrospective CDI query'?

Accepted Answer

A query issued after the patient has been discharged to clarify documentation for coding

Answer

A query issued before the patient is admitted

Answer

A verbal discussion with a nurse during rounds

Answer

A query sent to the insurance company for authorization

Question 5

Under AHIMA's CDI query guidelines, which of the following is NOT an appropriate reason to issue a physician query?

Accepted Answer

To increase reimbursement for a diagnosis not supported by clinical evidence

Answer

Conflicting documentation between providers

Answer

Clinical indicators supporting a higher-acuity diagnosis not documented

Answer

Ambiguous terminology that could represent multiple diagnoses

Question 6

What coding guideline applies when a patient is admitted for a condition that is a complication of a previous procedure?

Accepted Answer

Code the complication as the principal diagnosis if it meets the UHDDS definition

Answer

Code only the original condition from the prior procedure

Answer

Never code complications of prior procedures in inpatient settings

Answer

Code only the procedure performed during the current admission