CDIP - Certified Documentation Improvement Practitioner Record Review and Clarification Questions and Answers 1 — Questions and Answers
Question 1: A CDI professional reviews a record where a patient with a history of hypertension presents with shortness of breath, an ejection fraction of 30%, and is treated with IV diuretics. The physician has documented 'heart failure'. According to the 2022 AHIMA/ACDIS Practice Brief, which of the following is the most compliant query format to clarify the type and acuity of the heart failure?
- A 'Yes/No' query asking, 'Is the patient experiencing acute on chronic systolic heart failure?'
- A leading query suggesting, 'Based on the EF of 30% and IV diuretic use, please document acute systolic heart failure.'
- A multiple-choice query providing clinically supported options such as 'Acute systolic heart failure,' 'Chronic systolic heart failure,' 'Acute on chronic systolic heart failure,' and 'Unable to determine.' (Correct answer)
- An open-ended query stating, 'Please document a more specific diagnosis for the patient's heart failure to ensure proper reimbursement.'
Correct answer: A multiple-choice query providing clinically supported options such as 'Acute systolic heart failure,' 'Chronic systolic heart failure,' 'Acute on chronic systolic heart failure,' and 'Unable to determine.'
The 2022 AHIMA/ACDIS 'Guidelines for Achieving a Compliant Query Practice' recommends using a multiple-choice format when multiple clinically reasonable options exist. This format allows the provider to use their clinical judgment to select the most appropriate diagnosis based on the presented clinical indicators (low EF, symptoms, treatment) without being led to a specific answer. Mentioning reimbursement is non-compliant, and a Yes/No query is inappropriate for establishing this level of specificity when the initial diagnosis is already documented.
Question 2: During a concurrent record review, a CDI specialist identifies conflicting documentation regarding the cause of a patient's acute kidney injury (AKI). The emergency department physician documented 'AKI due to dehydration,' while the hospitalist noted 'AKI, likely due to ATN (Acute Tubular Necrosis).' What is the primary purpose of initiating a query in this scenario?
- To educate the emergency department physician on the pathophysiology of ATN.
- To determine which diagnosis will result in a higher MS-DRG assignment.
- To have the hospitalist confirm the final diagnosis for coding purposes.
- To resolve the conflicting documentation and ensure the health record is accurate and consistent. (Correct answer)
Correct answer: To resolve the conflicting documentation and ensure the health record is accurate and consistent.
A primary reason to initiate a query is to resolve conflicting, imprecise, incomplete, ambiguous, or inconsistent documentation within the health record. The goal is to ensure the final coded data accurately reflects the patient's condition and care, which requires a single, consistent diagnostic statement. The query should not be used to educate in a leading manner, be based on reimbursement, or favor one provider's documentation over another without clarification.
Question 3: Which of the following is a key principle of a compliant, non-leading physician query?
- Including the potential impact on quality scores to emphasize the importance of the query.
- Suggesting a diagnosis that is not yet documented but is suspected by the CDI professional.
- Citing specific clinical indicators from the patient's current health record to support the need for clarification. (Correct answer)
- Using a yes/no format to obtain a new diagnosis when only clinical indicators are present.
Correct answer: Citing specific clinical indicators from the patient's current health record to support the need for clarification.
Compliant queries must be based on and cite the specific clinical indicators found within the patient's health record for that episode of care. This provides the clinical evidence for why clarification is needed. Mentioning the impact on reimbursement or quality scores is strictly prohibited as it is considered leading. A new diagnosis cannot be introduced via a yes/no query; this format is reserved for clarifying diagnoses already documented.
Question 4: A CDI specialist is creating a query for a patient with documented anemia, a hemoglobin of 6.8 g/dL, and a positive fecal occult blood test. The physician has not linked the anemia to the suspected GI bleed. Which query statement is the most appropriate and non-leading?
- 'Please document acute blood loss anemia due to GI bleed, as this will more accurately reflect the patient's severity of illness.'
- 'Based on the hemoglobin of 6.8 g/dL and positive FOBT, can you please clarify the cause and/or acuity of the patient's anemia?' (Correct answer)
- 'Is the documented anemia due to acute blood loss from a GI bleed? (Yes/No)'
- 'Per coding guidelines, the relationship between the anemia and the GI bleed must be established. Please link these conditions.'
Correct answer: 'Based on the hemoglobin of 6.8 g/dL and positive FOBT, can you please clarify the cause and/or acuity of the patient's anemia?'
This option is an open-ended, non-leading question that presents the relevant clinical indicators (low hemoglobin, positive FOBT) and asks the provider to clarify the diagnosis using their clinical judgment. It does not direct the physician to a specific diagnosis, mention severity of illness impact, or improperly use a yes/no format. Referencing coding guidelines in a query is also considered inappropriate.
Question 5: When is it appropriate for a CDI professional to use a verbal query?
- When the CDI professional wants to avoid creating a permanent record of the interaction.
- When a quick 'yes' or 'no' answer is needed to add a new diagnosis.
- For simple clarifications that do not impact MS-DRG assignment.
- When a case is complex and may require a back-and-forth discussion to clarify multiple points. (Correct answer)
Correct answer: When a case is complex and may require a back-and-forth discussion to clarify multiple points.
Verbal queries are appropriate for complex cases where multiple clarifications might be needed, allowing for a real-time discussion. However, all verbal queries that impact coding must be documented in the record with the date, time, participants, clinical indicators discussed, and the provider's response, which must then be authenticated by the provider in the permanent health record.
Question 6: A post-discharge review of a patient's chart reveals clinical indicators strongly suggestive of sepsis (fever, tachycardia, leukocytosis, positive blood cultures) which was treated with IV antibiotics, but a definitive diagnosis of sepsis was never documented. What is the appropriate action for the CDI professional?
- Assume sepsis and recommend the coder add the diagnosis code.
- Send a retrospective multiple-choice query to the attending physician with the relevant clinical indicators, offering 'sepsis' as an option along with others like 'bacteremia' or 'clinically unable to determine.' (Correct answer)
- Do not query, as the patient has already been discharged and the opportunity is missed.
- Contact the physician and explain that failing to document sepsis will negatively affect the hospital's quality metrics.
Correct answer: Send a retrospective multiple-choice query to the attending physician with the relevant clinical indicators, offering 'sepsis' as an option along with others like 'bacteremia' or 'clinically unable to determine.'
Post-discharge (retrospective) queries are a standard and compliant practice when documentation is incomplete or conflicting. The most appropriate action is to send a non-leading query that presents the clinical evidence from the chart and provides clinically reasonable choices for the physician to make a final determination. It is never appropriate for a CDI specialist or coder to add a diagnosis without physician documentation, and mentioning the impact on metrics is non-compliant.
CDIP - Certified Documentation Improvement Practitioner Record Review and Clarification Questions and Answers 1
A CDI professional reviews a record where a patient with a history of hypertension presents with shortness of breath, an ejection fraction of 30%, and is treated with IV diuretics.
The physician has documented 'heart failure'.
According to the 2022 AHIMA/ACDIS Practice Brief, which of the following is the most compliant query format to clarify the type and acuity of the heart failure?