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

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?

Accepted Answer

Open-ended query offering clinically supported options without bias

Answer

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?

Accepted Answer

Sepsis

Answer

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?

Accepted Answer

Code pneumonia as if confirmed per UHDDS inpatient guidelines

Answer

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?

Accepted Answer

Complication or Comorbidity

Answer

In MS-DRG logic, CC stands for Complication or Comorbidity, a secondary diagnosis that increases the complexity and cost of care.

CIC - Certified Inpatient Coder Practice Test

CIC - Certified Inpatient Coder Practice Test

CIC CIC Clinical Documentation Improvement