CDIP - Certified Documentation Improvement Practitioner Physician Query Process Questions and Answers 1 — Questions and Answers
Question 1: A CDI professional reviews a record where the physician documented 'heart failure'. The echocardiogram shows an ejection fraction of 35% and the patient is on carvedilol and furosemide. Which of the following is the most compliant query to send to the physician?
- "The patient's ejection fraction is 35%. Please document acute on chronic systolic heart failure."
- "Based on the clinical indicators, can the type and acuity of the heart failure be further specified?" (Correct answer)
- "Is the patient's low ejection fraction of 35% indicative of systolic heart failure for better reimbursement?"
- "This patient has heart failure. Is it systolic, diastolic, or combined?"
Correct answer: "Based on the clinical indicators, can the type and acuity of the heart failure be further specified?"
This option is the most compliant because it is an open-ended, non-leading question that presents the need for clarification without suggesting a specific diagnosis or mentioning reimbursement. It allows the physician to use their clinical judgment to provide a more specific diagnosis based on the clinical indicators present in the record.
Question 2: According to the AHIMA/ACDIS Practice Brief, which of the following is an essential element of a compliant multiple-choice query?
- Including at least five clinically valid options to choose from.
- Listing the option with the highest reimbursement impact first.
- Providing an option such as 'other' or 'unable to determine' to allow the provider to add a free-text response. (Correct answer)
- Including ICD-10 codes next to each diagnostic option for clarity.
Correct answer: Providing an option such as 'other' or 'unable to determine' to allow the provider to add a free-text response.
The AHIMA/ACDIS guidelines state that a multiple-choice query should include options that are clinically supported by the health record and must provide a way for the physician to offer a different diagnosis or state they are unable to determine, ensuring the query is not restrictive or leading.
Question 3: A CDI specialist identifies conflicting documentation in a patient's chart. The emergency department physician documented 'pneumonia', while the hospitalist's progress note suggests 'acute exacerbation of CHF'. What is the primary purpose of initiating a physician query in this scenario?
- To force the physicians to agree on a single diagnosis.
- To resolve the discrepancy to ensure accurate code assignment and reflection of the patient's condition. (Correct answer)
- To determine which physician's documentation is more credible.
- To educate the emergency department physician on the signs of CHF.
Correct answer: To resolve the discrepancy to ensure accurate code assignment and reflection of the patient's condition.
The primary goal of a query in the case of conflicting documentation is to seek clarification from the attending provider to resolve the inconsistency. This ensures that the final coded data accurately reflects the patient's condition and the care provided.
Question 4: Which of the following situations would NOT be an appropriate reason to initiate a physician query?
- The physician documents a diagnosis of sepsis, but there are no clinical indicators such as fever, tachycardia, or elevated WBC in the record.
- The medical record contains illegible handwriting for the principal diagnosis.
- The CDI specialist believes a more specific diagnosis could be documented to increase the Case Mix Index (CMI). (Correct answer)
- The link between a patient's diabetes and a newly developed foot ulcer is not clearly documented.
Correct answer: The CDI specialist believes a more specific diagnosis could be documented to increase the Case Mix Index (CMI).
Queries should never be initiated solely to improve reimbursement or other reportable data. The purpose of a query is to clarify documentation based on clinical indicators present in the record, not to lead a physician to a diagnosis for financial gain.
Question 5: A patient's lab results show a sodium level of 125 mEq/L (low), and the physician has documented 'electrolyte imbalance'. A CDI specialist wants to query for a more specific diagnosis. Which query format is most appropriate and compliant?
- A Yes/No query stating: 'Do you agree the patient has hyponatremia?'
- A verbal query telling the physician to 'please add hyponatremia'.
- A multiple-choice query with 'hypernatremia' and 'hypokalemia' as options.
- An open-ended query stating: 'The patient's sodium is 125 mEq/L. Based on your clinical judgment, can this condition be further specified?' (Correct answer)
Correct answer: An open-ended query stating: 'The patient's sodium is 125 mEq/L. Based on your clinical judgment, can this condition be further specified?'
An open-ended query is the most compliant format in this situation. It presents the relevant clinical indicator (low sodium) and asks the physician to use their clinical judgment to provide a more specific diagnosis without leading them. A Yes/No query for a new diagnosis is non-compliant, and a multiple-choice query must only include clinically relevant options.
Question 6: What is the best practice for a CDI department to follow when a physician consistently does not respond to queries?
- Report the physician to the Chief Financial Officer for impeding revenue.
- Discontinue sending queries to that specific physician.
- Implement and follow a formal escalation policy that may involve a physician advisor. (Correct answer)
- Automatically code the chart using the most specific diagnosis suggested in the unanswered query.
Correct answer: Implement and follow a formal escalation policy that may involve a physician advisor.
The 2022 AHIMA/ACDIS Practice Brief recommends that organizations have an escalation process for unanswered queries. This process is not meant to be punitive but to facilitate communication and education, often involving a physician advisor or department leadership to address concerns and reinforce the importance of complete documentation.
CDIP - Certified Documentation Improvement Practitioner Physician Query Process Questions and Answers 1
A CDI professional reviews a record where the physician documented 'heart failure'.
The echocardiogram shows an ejection fraction of 35% and the patient is on carvedilol and furosemide.
Which of the following is the most compliant query to send to the physician?