CCDS CDI Strategies 2 — Questions and Answers
Question 1: Which CDI review method involves a CDI specialist examining charts while the patient is still hospitalized?
- Retrospective review
- Concurrent review (Correct answer)
- Prospective review
- Post-discharge review
Correct answer: Concurrent review
Concurrent review is performed while the patient is still admitted, allowing CDI specialists to query physicians in real time and obtain clarifying documentation before the record is finalized.
Concurrent review is the gold standard for CDI because it allows specialists to identify documentation gaps while the physician still has direct knowledge of the clinical situation. This timing results in higher query response rates and more accurate documentation compared to retrospective queries.
Question 2: A CDI specialist uses a 'working DRG' during concurrent review. What is the PRIMARY purpose of the working DRG?
- To bill the payer before the patient is discharged
- To predict the expected MS-DRG assignment based on current documentation (Correct answer)
- To calculate the patient's out-of-pocket cost estimate
- To replace the final coded DRG submitted on the claim
Correct answer: To predict the expected MS-DRG assignment based on current documentation
The working DRG is a real-time projection of the likely MS-DRG assignment based on documentation available during the stay. It helps CDI specialists identify gaps where additional physician documentation could support a more accurate DRG.
The working DRG is not a billing document but an internal CDI tool used to predict the DRG the case is trending toward. By comparing the working DRG to the expected DRG given the patient's clinical picture, CDI specialists can pinpoint specific documentation gaps and query the physician while the record is still active.
Question 3: Which of the following is the MOST important criterion when deciding whether to send a physician query?
- The query will likely result in a higher-weighted DRG
- There is a genuine clinical indicator in the record supporting a more specific diagnosis (Correct answer)
- The payer has requested additional documentation
- The patient's length of stay exceeds the GMLOS for the current working DRG
Correct answer: There is a genuine clinical indicator in the record supporting a more specific diagnosis
Queries must be clinically based. AHIMA and ACDIS guidelines require that queries be supported by clinical indicators in the medical record, not by financial motivation alone.
According to AHIMA and ACDIS query practice guidelines, every physician query must be supported by clinical indicators present in the medical record. Queries driven primarily by DRG optimization without clinical support violate compliance standards and can constitute fraud.
Question 4: A CDI specialist identifies that a patient with an open wound has documentation of 'possible osteomyelitis.' Under inpatient coding guidelines, how should this be coded?
- It cannot be coded; only confirmed diagnoses are coded
- It should be coded as osteomyelitis per the uncertain diagnosis guideline (Correct answer)
- It should be coded as a wound infection instead
- It should be flagged as a query but left uncoded pending confirmation
Correct answer: It should be coded as osteomyelitis per the uncertain diagnosis guideline
Under ICD-10-CM Official Coding Guidelines for inpatient settings, conditions documented as 'possible,' 'probable,' 'suspected,' or similar uncertainty terms at the time of discharge may be coded as if confirmed.
ICD-10-CM Official Guidelines Section II state that conditions documented as 'possible,' 'probable,' 'suspected,' 'likely,' 'questionable,' or 'still to be ruled out' at discharge are coded as if established. This inpatient-only guideline applies to conditions documented by the attending physician at the time of discharge.
Question 5: When a CDI specialist conducts a 'triggered review,' what typically initiates the review?
- A random selection of charts for quality auditing purposes
- Clinical criteria such as specific diagnoses, procedures, or LOS thresholds (Correct answer)
- A physician's request for documentation assistance
- A denial letter from a payer
Correct answer: Clinical criteria such as specific diagnoses, procedures, or LOS thresholds
Triggered reviews are initiated by automated or manual flags based on specific clinical criteria such as ICU stays, certain diagnoses, high-cost procedures, or LOS outliers.
Triggered reviews use predefined clinical and operational criteria to flag charts for CDI review. Common triggers include ICU admission, diagnoses such as sepsis or respiratory failure, procedures like mechanical ventilation, LOS exceeding the GMLOS, or specific ICD-10 codes that frequently pair with uncaptured CCs or MCCs.
Question 6: Which CDI metric measures how often physicians respond to queries compared to total queries sent?
- Query rate
- Query agreement rate
- Query response rate (Correct answer)
- Physician compliance rate
Correct answer: Query response rate
Query response rate measures the percentage of queries to which physicians provide a clinical response, regardless of whether the response results in a documentation change.
Query response rate is calculated as the number of queries answered divided by total queries sent. It is distinct from query agreement rate (percent of responses that add or confirm the queried diagnosis) and query impact rate (percent of queries that result in DRG or quality metric changes).
CCDS CDI Strategies 2
Which CDI review method involves a CDI specialist examining charts while the patient is still hospitalized?