RHIT Clinical Documentation Improvement 2

Question 1

Which metric is commonly used to measure the effectiveness of a CDI program?

Accepted Answer

Case Mix Index (CMI)

Answer

Number of patient complaints per month

Answer

Average length of patient stay before admission

Answer

Number of physician credentialing applications

Question 2

What is a 'present on admission' (POA) indicator used for?

Accepted Answer

To identify diagnoses that existed before the hospital stay for quality and payment purposes

Answer

To document conditions that developed during the inpatient stay

Answer

To flag records requiring physician signature

Answer

To indicate whether a diagnosis was confirmed by lab results

Question 3

Which of the following documentation practices supports accurate MS-DRG assignment?

Accepted Answer

Clearly documenting complications and comorbidities (CCs) and major CCs (MCCs)

Answer

Documenting 'rule out' diagnoses as confirmed

Answer

Listing all diagnoses alphabetically

Answer

Avoiding documentation of secondary diagnoses

Question 4

A CDI specialist finds that a physician documented 'sepsis' but clinical indicators suggest 'severe sepsis.' What is the CDI specialist's role?

Accepted Answer

Query the physician to confirm whether severe sepsis criteria are met

Answer

Upgrade the code to severe sepsis without querying

Answer

Discard the record for re-documentation

Answer

Report the physician to administration

Question 5

Which type of CDI query is sent while the patient is still admitted?

Accepted Answer

Concurrent query

Answer

Retrospective query

Answer

Post-discharge query

Answer

Denial management query

Question 6

What does 'severity of illness' (SOI) measure in the context of clinical documentation?

Accepted Answer

The extent of physiologic decompensation or organ system loss of function

Answer

The financial cost of the patient's treatment

Answer

The number of procedures performed during the stay

Answer

The patient's subjective pain level on admission