CDIP Record Review and Clarification 2 — Questions and Answers
Question 1: A CDI specialist reviews a record where the attending documents 'sepsis' but the blood cultures are negative and antibiotics were discontinued after 48 hours. What is the most appropriate action?
- Accept the diagnosis as documented without query
- Query the physician asking whether sepsis or an alternative diagnosis better reflects the clinical picture (Correct answer)
- Change the diagnosis to 'suspected infection' in the coding system
- Escalate to the compliance department immediately
Correct answer: Query the physician asking whether sepsis or an alternative diagnosis better reflects the clinical picture
When clinical indicators don't fully support a documented diagnosis, a compliant query seeking clarification of the most accurate diagnosis is appropriate.
Question 2: Which type of query format presents a list of diagnosis options based on clinical indicators and asks the physician to select, add, or indicate 'none of the above'?
- Open-ended query
- Multiple-choice query (Correct answer)
- Leading query
- Verbal-only query
Correct answer: Multiple-choice query
A multiple-choice query offers clinically supported options and a 'none of the above' choice to remain compliant and non-leading.
Question 3: A query is sent regarding a patient with a BMI of 42 and documentation of 'overweight.' The physician does not respond. How should the CDI specialist proceed?
- Code obesity based on the BMI value alone
- Leave the query open and follow up per facility policy (Correct answer)
- Close the query and code 'overweight' as documented
- Request that the coder make the change without physician input
Correct answer: Leave the query open and follow up per facility policy
Unanswered queries should be followed up according to facility policy; coders cannot assign a diagnosis absent physician documentation.
Question 4: During concurrent review, a CDI specialist notes a patient is receiving IV insulin drip and frequent glucose checks but 'diabetes' is not documented. What is the best approach?
- Code type 2 diabetes based on the treatment
- Query the physician to clarify whether a diabetic condition exists (Correct answer)
- Wait until discharge to review the record
- Document diabetes in the clinical data field of the encoder
Correct answer: Query the physician to clarify whether a diabetic condition exists
Concurrent CDI review allows timely queries so physicians can clarify diagnoses before discharge, improving accuracy.
Question 5: Which statement best describes a 'leading' query and why it is non-compliant?
- It offers multiple clinical options and is compliant
- It suggests a specific diagnosis without adequate clinical basis, influencing the physician's response inappropriately (Correct answer)
- It is sent verbally and lacks a written record
- It is compliant if the physician agrees with the suggestion
Correct answer: It suggests a specific diagnosis without adequate clinical basis, influencing the physician's response inappropriately
A leading query steers the physician toward a specific, often higher-reimbursing diagnosis without sufficient clinical justification, violating query integrity standards.
Question 6: A patient's record documents 'acute renal failure' on admission but the final diagnoses list only 'chronic kidney disease stage 3.' What should the CDI specialist do?
- Code only chronic kidney disease as it is the final diagnosis
- Query the physician to clarify whether acute-on-chronic kidney disease or AKF resolved should be documented (Correct answer)
- Add acute renal failure to the problem list independently
- Ignore the discrepancy since the final diagnoses govern coding
Correct answer: Query the physician to clarify whether acute-on-chronic kidney disease or AKF resolved should be documented
Discrepancies between admission documentation and discharge summary warrant a clarifying query to ensure accurate final coding.
Question 7: Post-discharge retrospective queries are considered appropriate in which scenario?
- Whenever the CDI specialist wants a higher-weighted DRG
- When a clinical indicator was present during the stay but the opportunity was missed during concurrent review (Correct answer)
- When the physician's original documentation was clear and complete
- Only when the patient is readmitted within 30 days
Correct answer: When a clinical indicator was present during the stay but the opportunity was missed during concurrent review
Retrospective queries are appropriate when a legitimate documentation gap existed during the encounter that was not addressed concurrently.
CDIP Record Review and Clarification 2
A CDI specialist reviews a record where the attending documents 'sepsis' but the blood cultures are negative and antibiotics were discontinued after 48 hours.
What is the most appropriate action?