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

Malnutrition severity (mild, moderate, severe) significantly impacts DRG assignment, so CDI specialists should query for specificity when documentation is vague.

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

The POA indicator differentiates conditions present at admission from those that developed during the hospital stay, which is critical for hospital-acquired condition (HAC) reporting and payment penalties.

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

When clinical findings such as lab results are not addressed in the physician's documentation, CDI specialists should query the physician rather than code directly from lab data alone.

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

Retrospective queries are issued after patient discharge when documentation gaps or ambiguities are discovered during the coding process.

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

Queries must be clinically supported and cannot be issued solely to increase reimbursement without corresponding clinical evidence, as this would violate compliance standards.

CIC - Certified Inpatient Coder Practice Test

CIC - Certified Inpatient Coder Practice Test

CIC CIC Clinical Documentation Improvement 3