CIC CIC Clinical Documentation Improvement 1 — Questions and Answers
Question 1: What is the primary goal of a Clinical Documentation Improvement (CDI) program in an inpatient setting?
- Reduce nursing workload
- Ensure clinical documentation accurately reflects patient severity and supports appropriate code assignment (Correct answer)
- Speed up patient discharge
- Lower hospital operating costs
Correct answer: Ensure clinical documentation accurately reflects patient severity and supports appropriate code assignment
CDI programs exist to ensure that clinical documentation fully and accurately captures patient acuity so that coding reflects the true severity of illness.
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?
- Leading query suggesting a specific diagnosis
- Open-ended query offering clinically supported options without bias (Correct answer)
- Verbal-only query with no documentation
- Query demanding a single specific answer
Correct answer: Open-ended query offering clinically supported options without bias
AHIMA guidelines require queries to be non-leading, offering multiple clinically supported options or an open-ended format to avoid influencing the physician's clinical judgment.
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?
- Hypertension, controlled
- Sepsis (Correct answer)
- Routine urinary tract infection
- Mild anemia
Correct answer: Sepsis
Sepsis is an MCC (Major Complication or Comorbidity) that frequently causes a significant DRG upgrade when documented and coded correctly.
Question 4: A CDI specialist reviews a record where the physician documents 'possible pneumonia.' How should an inpatient coder handle this?
- Code only the signs and symptoms
- Code pneumonia as if confirmed per UHDDS inpatient guidelines (Correct answer)
- Query the physician before assigning any code
- Leave the diagnosis field blank
Correct answer: Code pneumonia as if confirmed per UHDDS inpatient guidelines
Per UHDDS inpatient guidelines, uncertain diagnoses documented as 'possible,' 'probable,' or 'suspected' at the time of discharge are coded as if confirmed.
Question 5: What does 'CC' stand for in the context of MS-DRG assignment?
- Clinical Compliance
- Complication or Comorbidity (Correct answer)
- Certified Coder
- Charge Capture
Correct answer: Complication or Comorbidity
In MS-DRG logic, CC stands for Complication or Comorbidity, a secondary diagnosis that increases the complexity and cost of care.
Question 6: Which document serves as the primary source for CDI specialists when determining whether a query is clinically supported?
- The hospital billing statement
- The physician's progress notes, lab results, and diagnostic reports in the medical record (Correct answer)
- The insurance authorization form
- The patient's advance directive
Correct answer: The physician's progress notes, lab results, and diagnostic reports in the medical record
CDI queries must be grounded in clinical evidence found in the medical record, including progress notes, lab values, imaging, and other diagnostic data.
CIC CIC Clinical Documentation Improvement 1
What is the primary goal of a Clinical Documentation Improvement (CDI) program in an inpatient setting?