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 Present on Admission (POA) indicator is crucial for all HACs. If the signs/symptoms of the UTI were present when the patient was admitted, even if the formal diagnosis was made later, it would be considered POA and not a HAC.

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

PSI 12 has specific exclusions. If a patient had a DVT within 30 days prior to admission, the post-operative DVT is not considered a new complication for the purposes of this quality measure. Clarifying this history is a key CDI role.

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

The main purpose of a mortality review from a CDI perspective is to ensure the documentation fully captures all active conditions and their severity. This leads to accurate coding that reflects the patient's true severity of illness (SOI) and risk of mortality (ROM), which is crucial for risk-adjusted mortality metrics.

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

HRRP penalizes hospitals for excess readmissions for certain conditions. If the readmission is for a clearly distinct and unrelated clinical problem, it may not count against the hospital's performance for the initial condition. CDI can help by ensuring the principal diagnosis for the second stay is clearly and accurately documented.

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

PSI 02 flags deaths in what are expected to be low-risk admissions. The key to accurately reflecting the patient's risk is to capture all co-existing, active secondary diagnoses that contribute to a higher risk of mortality, such as severe sepsis, acute respiratory failure, or metastatic cancer. This demonstrates the patient was sicker than the principal diagnosis alone would suggest.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

FREE CCDS CDI and Quality Metrics Questions and Answers