FREE CCDS CDI and Quality Metrics Questions and Answers

Question 1

A patient develops a catheter-associated urinary tract infection (CAUTI) on day 4 of admission.
Which piece of documentation is most critical for determining if this is a Hospital-Acquired Condition (HAC)?

Accepted Answer

Documentation of signs/symptoms of UTI being present on admission (POA).

Answer

The type of antibiotic used to treat the infection.

Answer

The patient's age and gender.

Answer

The specialty of the attending physician.

Question 2

A patient undergoes a total knee replacement and develops a deep vein thrombosis (DVT) on post-op day 3. Which documentation could potentially exclude this case from the PSI 12 (Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate) measure?

Accepted Answer

Documentation of a history of DVT within the 30 days prior to admission.

Answer

Documentation that the patient received appropriate DVT prophylaxis.

Answer

Documentation that the surgery was elective.

Answer

Documentation that the patient ambulated on post-op day 1.

Question 3

What is the primary goal of a CDI mortality review?

Accepted Answer

To ensure the final coded data accurately reflects the patient's severity of illness and risk of mortality.

Answer

To determine the cause of death for the death certificate.

Answer

To assign blame for any potential medical errors.

Answer

To communicate with the patient's family about the hospital stay.

Question 4

A patient is readmitted 15 days after discharge for pneumonia with a new diagnosis of acute MI. How can CDI documentation impact the classification of this readmission under the Hospital Readmissions Reduction Program (HRRP)?

Accepted Answer

By ensuring documentation clearly supports that the MI is an unrelated, new problem, making it a distinct admission.

Answer

By querying to link the MI to the previous pneumonia admission.

Answer

By documenting the readmission as 'planned' in the physician's notes.

Answer

By changing the principal diagnosis of the first admission to something other than pneumonia.

Question 5

A patient admitted for a simple UTI (a low-mortality DRG) dies unexpectedly. A CDI review is initiated to assess for PSI 02 (Death in Low-Mortality DRGs). What is the most important documentation focus for the CDI specialist?

Accepted Answer

Identifying and clarifying all active comorbidities and complications that increase the risk of mortality.

Answer

Ensuring the documentation of the patient's code status (e.g., DNR).

Answer

Confirming the patient's age and discharge disposition.

Answer

Verifying that the correct antibiotics were administered for the UTI.

Question 6

How does accurate documentation of complications and comorbidities (CCs/MCCs) directly impact a hospital's performance in the Value-Based Purchasing (VBP) program?

Accepted Answer

It ensures accurate risk adjustment, providing a more precise reflection of expected outcomes for a given patient population.

Answer

It increases the length of stay, which is a positive VBP metric.

Answer

It directly increases the payment for every admission, regardless of quality.

Answer

It guarantees the hospital will receive a bonus payment from CMS.

A patient develops a catheter-associated urinary tract infection (CAUTI) on day 4 of admission.Which piece of documentation is most critical for determining if this is a Hospital-Acquired Condition (HAC)?

A patient develops a catheter-associated urinary tract infection (CAUTI) on day 4 of admission.
Which piece of documentation is most critical for determining if this is a Hospital-Acquired Condition (HAC)?