CIC CIC Clinical Documentation Improvement

Question 1

What is the primary goal of a Clinical Documentation Improvement (CDI) program in an inpatient setting?

Accepted Answer

Ensure clinical documentation accurately reflects patient severity and supports appropriate code assignment

Answer

Reduce nursing workload

Answer

Speed up patient discharge

Answer

Lower hospital operating costs

Question 2

A CDI specialist issues a query to a physician about a patient with acute respiratory failure. What type of query format is generally considered compliant per AHIMA guidelines?

Accepted Answer

Open-ended query offering clinically supported options without bias

Answer

Leading query suggesting a specific diagnosis

Answer

Verbal-only query with no documentation

Answer

Query demanding a single specific answer

Question 3

Which condition, when documented by a physician, most commonly upgrades a DRG from a lower-paying to a higher-paying MS-DRG due to MCC status?

Accepted Answer

Sepsis

Answer

Hypertension, controlled

Answer

Routine urinary tract infection

Answer

Mild anemia

Question 4

A CDI specialist reviews a record where the physician documents 'possible pneumonia.' How should an inpatient coder handle this?

Accepted Answer

Code pneumonia as if confirmed per UHDDS inpatient guidelines

Answer

Code only the signs and symptoms

Answer

Query the physician before assigning any code

Answer

Leave the diagnosis field blank

Question 5

What does 'CC' stand for in the context of MS-DRG assignment?

Accepted Answer

Complication or Comorbidity

Answer

Clinical Compliance

Answer

Certified Coder

Answer

Charge Capture

Question 6

Which document serves as the primary source for CDI specialists when determining whether a query is clinically supported?

Accepted Answer

The physician's progress notes, lab results, and diagnostic reports in the medical record

Answer

The hospital billing statement

Answer

The insurance authorization form

Answer

The patient's advance directive