CRC Clinical Documentation Improvement 2

Question 1

A CDI specialist reviews a chart where the physician documents 'CHF' without further specification. Which query would be most effective for risk adjustment?

Accepted Answer

What is the heart failure type, acuity, and current severity class?

Answer

Is the heart failure systolic, diastolic, or combined?

Answer

Does the patient have acute or chronic heart failure?

Answer

Should we code I50.9 for unspecified heart failure?

Question 2

A CDI specialist notices lab values showing eGFR of 22 mL/min but the physician only documents 'renal insufficiency.' What is the appropriate CDI action?

Accepted Answer

Query the provider to document CKD stage consistent with the eGFR findings

Answer

Code N18.4 for CKD stage 4 based on lab values alone

Answer

Document the CKD stage in a CDI note for the coder

Answer

Wait for the discharge summary for additional specificity

Question 3

A physician documents 'patient is malnourished.' The dietitian's assessment documents 'severe protein-calorie malnutrition with BMI 15.2.' For CDI purposes, which source can be used?

Accepted Answer

A CDI query should be generated for the physician to confirm the severity

Answer

Only the physician's documentation

Answer

The dietitian's assessment directly

Answer

Both sources are equally valid

Question 4

A CDI team finds query response rate dropped from 85% to 60%. Which strategy is most likely to improve physician engagement?

Accepted Answer

Redesign queries to be more specific with clinical indicators and response checkboxes

Answer

Implement mandatory query response requirements with consequences

Answer

Reduce queries to only target high-value HCC conditions

Answer

Switch from concurrent to retrospective queries

Question 5

Which documentation improvement scenario would have the greatest positive impact on risk adjustment accuracy?

Accepted Answer

Changing 'diabetes' to 'diabetes mellitus type 2 with diabetic nephropathy' when supported by evidence

Answer

Adding BMI values to every encounter for patients with obesity

Answer

Documenting medication lists in detail for every visit

Answer

Recording vital signs with greater precision

Question 6

A CDI specialist finds a patient admitted for pneumonia also has chronic respiratory failure with home oxygen documented on the problem list but not addressed in the current encounter. What action is appropriate?

Accepted Answer

Query the provider to address the chronic respiratory failure in the current encounter

Answer

No action needed since it is on the problem list

Answer

Add a CDI note referencing the problem list

Answer

Remove the condition from consideration