CCDS CDI Strategies 2

Question 1

Which CDI review method involves a CDI specialist examining charts while the patient is still hospitalized?

Accepted Answer

Concurrent review

Answer

Concurrent review is performed while the patient is still admitted, allowing CDI specialists to query physicians in real time and obtain clarifying documentation before the record is finalized.

Question 2

A CDI specialist uses a 'working DRG' during concurrent review. What is the PRIMARY purpose of the working DRG?

Accepted Answer

To predict the expected MS-DRG assignment based on current documentation

Answer

The working DRG is a real-time projection of the likely MS-DRG assignment based on documentation available during the stay. It helps CDI specialists identify gaps where additional physician documentation could support a more accurate DRG.

Question 3

Which of the following is the MOST important criterion when deciding whether to send a physician query?

Accepted Answer

There is a genuine clinical indicator in the record supporting a more specific diagnosis

Answer

Queries must be clinically based. AHIMA and ACDIS guidelines require that queries be supported by clinical indicators in the medical record, not by financial motivation alone.

Question 4

A CDI specialist identifies that a patient with an open wound has documentation of 'possible osteomyelitis.' Under inpatient coding guidelines, how should this be coded?

Accepted Answer

It should be coded as osteomyelitis per the uncertain diagnosis guideline

Answer

Under ICD-10-CM Official Coding Guidelines for inpatient settings, conditions documented as 'possible,' 'probable,' 'suspected,' or similar uncertainty terms at the time of discharge may be coded as if confirmed.

Question 5

When a CDI specialist conducts a 'triggered review,' what typically initiates the review?

Accepted Answer

Clinical criteria such as specific diagnoses, procedures, or LOS thresholds

Answer

Triggered reviews are initiated by automated or manual flags based on specific clinical criteria such as ICU stays, certain diagnoses, high-cost procedures, or LOS outliers.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS CDI Strategies 2