CCDS Compliant Query Formulation 2

Question 1

According to AHIMA/ACDIS query practice guidelines, which of the following query formats is MOST compliant?

Accepted Answer

A multiple-choice query offering clinically appropriate diagnoses plus 'other' and 'clinically undetermined'

Answer

AHIMA/ACDIS guidelines require non-leading queries that offer balanced clinical options. Multiple-choice formats listing plausible diagnoses plus 'other' and 'clinically undetermined' meet this standard.

Question 2

Which of the following query scenarios represents an INAPPROPRIATE use of a physician query?

Accepted Answer

Querying to document sepsis when the only basis is a desire to capture an MCC

Answer

Queries must be based on clinical indicators in the record, not on financial motivations. Sending a query to capture an MCC designation for sepsis without any clinical indicators supporting sepsis is non-compliant and potentially fraudulent.

Question 3

When is a verbal physician query considered acceptable under CDI compliance standards?

Accepted Answer

Only when the written query response is also documented in the medical record

Answer

Verbal queries may be used but are only acceptable if the physician's response and the clinical basis for the query are documented in the medical record.

Question 4

A CDI specialist sends a query for hypertensive heart disease. The physician responds 'clinically undetermined.' What is the correct action?

Accepted Answer

Accept the response and code without hypertensive heart disease

Answer

When a physician responds 'clinically undetermined,' the CDI specialist must accept the response and code the case without the queried diagnosis. Physician responses including negative responses must be honored.

Question 5

Which element is REQUIRED to be included in every compliant physician query?

Accepted Answer

Clinical indicators from the medical record that prompted the query

Answer

Every compliant query must cite the specific clinical indicators from the medical record that prompted the question. This demonstrates that the query is clinically based and not financially motivated.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Compliant Query Formulation 2