Clinical Documentation Improvement Flashcards
6 cards from real RHIT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Clinical Documentation Improvement flashcards as text
What is the primary goal of a Clinical Documentation Improvement (CDI) program?
Answer: Ensure physician documentation accurately reflects the severity of illness and quality of care
CDI programs ensure that physician documentation accurately and completely reflects the patient's clinical status to support accurate coding, reimbursement, and quality reporting.
A CDI specialist reviews a record and notices a patient was treated for 'respiratory failure' but only 'pneumonia' is documented. What should the CDI specialist do?
Answer: Submit a query to the physician to clarify the diagnosis
CDI specialists submit physician queries to clarify ambiguous or incomplete documentation rather than assuming or altering records.
Which of the following is an example of a compliant physician query format?
Answer: A query presenting multiple clinically supported options including 'other' and 'undetermined'
Compliant queries are non-leading, present multiple supported options, and include clinical indicators to guide physician response.
What does the term 'principal diagnosis' mean in the context of inpatient coding?
Answer: The condition established after study to be chiefly responsible for the admission
The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the hospital admission.
Which organization publishes the Official Guidelines for Coding and Reporting used by CDI specialists?
Answer: Centers for Medicare & Medicaid Services (CMS) and National Center for Health Statistics (NCHS)
CMS and NCHS jointly publish the ICD-10-CM Official Guidelines for Coding and Reporting, which govern diagnosis code assignment.
A patient's record shows a blood glucose of 450 mg/dL and the physician documents 'hyperglycemia.' A CDI specialist queries for diabetes mellitus with hyperglycemia. This query is appropriate because:
Answer: Clinical indicators in the record support a more specific diagnosis
When clinical indicators such as lab values support a more specific diagnosis, a compliant query may be submitted to the physician for clarification.