RHIT Clinical Documentation Improvement 2 — Questions and Answers
Question 1: Which metric is commonly used to measure the effectiveness of a CDI program?
- Number of patient complaints per month
- Case Mix Index (CMI) (Correct answer)
- Average length of patient stay before admission
- Number of physician credentialing applications
Correct answer: Case Mix Index (CMI)
The Case Mix Index reflects the average DRG weight of a facility's patients and is a key indicator of CDI program impact on reimbursement accuracy.
Question 2: What is a 'present on admission' (POA) indicator used for?
- To identify diagnoses that existed before the hospital stay for quality and payment purposes (Correct answer)
- To document conditions that developed during the inpatient stay
- To flag records requiring physician signature
- To indicate whether a diagnosis was confirmed by lab results
Correct answer: To identify diagnoses that existed before the hospital stay for quality and payment purposes
POA indicators identify whether a diagnosis was present at the time of inpatient admission, affecting hospital-acquired condition (HAC) reporting and reimbursement.
Question 3: Which of the following documentation practices supports accurate MS-DRG assignment?
- Documenting 'rule out' diagnoses as confirmed
- Clearly documenting complications and comorbidities (CCs) and major CCs (MCCs) (Correct answer)
- Listing all diagnoses alphabetically
- Avoiding documentation of secondary diagnoses
Correct answer: Clearly documenting complications and comorbidities (CCs) and major CCs (MCCs)
Documenting CCs and MCCs is critical because they affect MS-DRG grouping, which determines inpatient reimbursement under Medicare.
Question 4: A CDI specialist finds that a physician documented 'sepsis' but clinical indicators suggest 'severe sepsis.' What is the CDI specialist's role?
- Upgrade the code to severe sepsis without querying
- Query the physician to confirm whether severe sepsis criteria are met (Correct answer)
- Discard the record for re-documentation
- Report the physician to administration
Correct answer: Query the physician to confirm whether severe sepsis criteria are met
CDI specialists should query physicians when clinical evidence suggests a more specific or serious condition than what is currently documented.
Question 5: Which type of CDI query is sent while the patient is still admitted?
- Retrospective query
- Concurrent query (Correct answer)
- Post-discharge query
- Denial management query
Correct answer: Concurrent query
Concurrent queries are issued during the patient's stay, allowing physicians to update documentation before discharge, which is preferred for accuracy.
Question 6: What does 'severity of illness' (SOI) measure in the context of clinical documentation?
- The financial cost of the patient's treatment
- The extent of physiologic decompensation or organ system loss of function (Correct answer)
- The number of procedures performed during the stay
- The patient's subjective pain level on admission
Correct answer: The extent of physiologic decompensation or organ system loss of function
Severity of illness measures the degree of loss of physiologic function, which is used in risk-adjusted quality measures and APR-DRG grouping.
RHIT Clinical Documentation Improvement 2
Which metric is commonly used to measure the effectiveness of a CDI program?