Clinical Documentation Improvement Flashcards

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

Answer: Case Mix Index (CMI)

The Case Mix Index reflects the average DRG weight of a facility's patients and is a key indicator of CDI program impact on reimbursement accuracy.

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

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

POA indicators identify whether a diagnosis was present at the time of inpatient admission, affecting hospital-acquired condition (HAC) reporting and reimbursement.

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

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

Documenting CCs and MCCs is critical because they affect MS-DRG grouping, which determines inpatient reimbursement under Medicare.

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

Answer: Query the physician to confirm whether severe sepsis criteria are met

CDI specialists should query physicians when clinical evidence suggests a more specific or serious condition than what is currently documented.

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

Answer: Concurrent query

Concurrent queries are issued during the patient's stay, allowing physicians to update documentation before discharge, which is preferred for accuracy.

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

Answer: The extent of physiologic decompensation or organ system loss of function

Severity of illness measures the degree of loss of physiologic function, which is used in risk-adjusted quality measures and APR-DRG grouping.