AHIMA AHIMA Clinical Documentation Improvement 1 — Questions and Answers
Question 1: What is the primary goal of a Clinical Documentation Improvement (CDI) program in a US hospital?
- Reduce nursing documentation time
- Ensure clinical documentation accurately reflects patient severity and resource utilization (Correct answer)
- Increase the number of coded diagnoses per chart
- Speed up the discharge process
Correct answer: Ensure clinical documentation accurately reflects patient severity and resource utilization
CDI programs aim to ensure that clinical documentation accurately captures the patient's severity of illness and the resources used in their care.
Question 2: Which query type asks a physician to clarify documentation without suggesting a specific diagnosis?
- Leading query
- Non-leading query (Correct answer)
- Closed query
- Retrospective query
Correct answer: Non-leading query
A non-leading query presents clinical indicators and asks the physician to provide their clinical interpretation without suggesting an answer.
Question 3: What does the term 'principal diagnosis' mean in the context of US inpatient coding under UHDDS guidelines?
- The most severe diagnosis the patient has
- The condition established after study to be chiefly responsible for the admission (Correct answer)
- The first diagnosis listed by the physician
- The diagnosis that generated the most charges
Correct answer: The condition established after study to be chiefly responsible for the admission
The Uniform Hospital Discharge Data Set (UHDDS) defines the principal diagnosis as the condition established after study to be chiefly responsible for causing the admission.
Question 4: Which condition must be documented by the physician for a CDI specialist to query for 'malnutrition' to affect MS-DRG assignment?
- Low albumin level only
- BMI below 18.5
- Clinical indicators such as poor intake, weight loss, or muscle wasting documented alongside a clinical diagnosis (Correct answer)
- Any mention of dietary restrictions
Correct answer: Clinical indicators such as poor intake, weight loss, or muscle wasting documented alongside a clinical diagnosis
Malnutrition requires a physician's clinical diagnosis supported by documented indicators; lab values alone are insufficient for coding purposes.
Question 5: What is a 'concurrent' CDI review?
- Review performed after the patient is discharged
- Review performed while the patient is still admitted (Correct answer)
- Review performed only on surgical cases
- Review performed by an external auditor
Correct answer: Review performed while the patient is still admitted
Concurrent CDI review occurs while the patient is still hospitalized, allowing queries to be answered before discharge and the record is coded.
Question 6: Under ICD-10-CM/PCS guidelines, when is it appropriate to code a condition as 'present on admission' (POA)?
- When the condition develops within 24 hours of admission
- When the condition exists at the time the order for inpatient admission occurs (Correct answer)
- When the condition is documented on the face sheet
- When the attending physician designates it as pre-existing
Correct answer: When the condition exists at the time the order for inpatient admission occurs
POA is defined as a condition present at the time the order for inpatient admission is made, including conditions that develop during an outpatient encounter that results in admission.
AHIMA AHIMA Clinical Documentation Improvement 1
What is the primary goal of a Clinical Documentation Improvement (CDI) program in a US hospital?