CDIP Clinical Validation Principles 2 — Questions and Answers
Question 1: A physician documents 'acute kidney injury' in a patient with a creatinine of 1.2 mg/dL (baseline 1.0). A CDI specialist reviews the record and finds no clinical indicators supporting AKI. What is the most appropriate action?
- Accept the diagnosis as documented without question
- Query the physician to clarify if clinical indicators support the AKI diagnosis (Correct answer)
- Change the diagnosis to 'abnormal creatinine' without querying
- Ignore the documentation and code based on lab values alone
Correct answer: Query the physician to clarify if clinical indicators support the AKI diagnosis
Clinical validation requires querying the physician when documented diagnoses lack supporting clinical indicators, not unilaterally changing or ignoring documentation.
Question 2: Which organization's 'Coding Clinic' guidance is the authoritative source for ICD-10-CM/PCS coding advice that CDI specialists must follow?
- Centers for Medicare & Medicaid Services (CMS)
- American Health Information Management Association (AHIMA)
- American Hospital Association (AHA) (Correct answer)
- The Joint Commission (TJC)
Correct answer: American Hospital Association (AHA)
The AHA's Coding Clinic is the official publication providing authoritative ICD-10-CM/PCS coding guidance recognized by CMS.
Question 3: When performing clinical validation of a sepsis diagnosis, which set of criteria is most commonly referenced to determine clinical support?
- Ranson's criteria
- SOFA/qSOFA and Sepsis-3 definitions (Correct answer)
- Child-Pugh score
- APACHE II score alone
Correct answer: SOFA/qSOFA and Sepsis-3 definitions
The Sepsis-3 consensus definitions using SOFA and qSOFA scores are the current standard for clinically validating sepsis diagnoses.
Question 4: A CDI specialist disagrees with a physician's documented diagnosis based on clinical indicators. After querying, the physician affirms the diagnosis. What should the CDI specialist do?
- Escalate to the compliance department to override the physician
- Accept the physician's clinical judgment and document the query outcome (Correct answer)
- Submit the case to the coding team to code a different diagnosis
- Remove the query from the record
Correct answer: Accept the physician's clinical judgment and document the query outcome
Physicians hold final clinical authority; CDI specialists must respect physician judgment after a query and cannot unilaterally override documented diagnoses.
Question 5: Which of the following best describes the concept of 'clinical criteria' in the context of clinical validation?
- Only laboratory values that confirm a diagnosis
- Signs, symptoms, lab results, imaging, and treatment that collectively support a diagnosis (Correct answer)
- The physician's subjective impression documented in the assessment
- Diagnostic codes assigned by the coding team
Correct answer: Signs, symptoms, lab results, imaging, and treatment that collectively support a diagnosis
Clinical criteria encompass the full spectrum of objective and subjective findings—labs, vitals, imaging, symptoms, and treatment—that together support or refute a documented diagnosis.
Question 6: A hospital implements a clinical validation program that results in frequent downgrades of diagnoses. Which risk does this primarily expose the hospital to?
- Increased DRG weight and higher reimbursement
- Potential allegations of improper denial of legitimate diagnoses and upcoding in reverse (Correct answer)
- Reduced physician satisfaction only
- Improved accuracy with no compliance risk
Correct answer: Potential allegations of improper denial of legitimate diagnoses and upcoding in reverse
Systematic downgrading without clinical justification can constitute improper claim manipulation and trigger OIG scrutiny for undercoding or denial of legitimate conditions.
Question 7: Which document type is NOT an appropriate reference source for clinical validation of a malnutrition diagnosis?
- Dietitian's nutritional assessment note
- Physician's history and physical
- Insurance company's prior authorization denial letter (Correct answer)
- Nursing intake and output documentation
Correct answer: Insurance company's prior authorization denial letter
Payer documents like prior authorization denials are administrative, not clinical, and cannot be used as clinical evidence to validate or invalidate a diagnosis.
CDIP Clinical Validation Principles 2
A physician documents 'acute kidney injury' in a patient with a creatinine of 1.2 mg/dL (baseline 1.0).
A CDI specialist reviews the record and finds no clinical indicators supporting AKI.
What is the most appropriate action?