RHIT Clinical Documentation Improvement 1 — Questions and Answers
Question 1: What is the primary goal of a Clinical Documentation Improvement (CDI) program?
- Reduce the number of patient admissions
- Ensure physician documentation accurately reflects the severity of illness and quality of care (Correct answer)
- Eliminate all paper records from the health system
- Increase the number of coded diagnoses per encounter
Correct answer: Ensure physician documentation accurately reflects the severity of illness and quality of care
CDI programs ensure that physician documentation accurately and completely reflects the patient's clinical status to support accurate coding, reimbursement, and quality reporting.
Question 2: A CDI specialist reviews a record and notices a patient was treated for 'respiratory failure' but only 'pneumonia' is documented. What should the CDI specialist do?
- Code respiratory failure without physician documentation
- Submit a query to the physician to clarify the diagnosis (Correct answer)
- Ignore the discrepancy and code only what is documented
- Change the documentation to reflect respiratory failure
Correct answer: Submit a query to the physician to clarify the diagnosis
CDI specialists submit physician queries to clarify ambiguous or incomplete documentation rather than assuming or altering records.
Question 3: Which of the following is an example of a compliant physician query format?
- A leading query that suggests a specific diagnosis
- A query presenting multiple clinically supported options including 'other' and 'undetermined' (Correct answer)
- A verbal-only query with no documentation
- A query sent to a non-treating provider
Correct answer: A query presenting multiple clinically supported options including 'other' and 'undetermined'
Compliant queries are non-leading, present multiple supported options, and include clinical indicators to guide physician response.
Question 4: What does the term 'principal diagnosis' mean in the context of inpatient coding?
- The condition that caused the patient to seek care initially
- The condition established after study to be chiefly responsible for the admission (Correct answer)
- The most expensive condition to treat
- The first diagnosis listed in the problem list
Correct answer: The condition established after study to be chiefly responsible for the admission
The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the hospital admission.
Question 5: Which organization publishes the Official Guidelines for Coding and Reporting used by CDI specialists?
- American Health Information Management Association (AHIMA)
- Centers for Medicare & Medicaid Services (CMS) and National Center for Health Statistics (NCHS) (Correct answer)
- The Joint Commission (TJC)
- American Medical Association (AMA)
Correct answer: Centers for Medicare & Medicaid Services (CMS) and National Center for Health Statistics (NCHS)
CMS and NCHS jointly publish the ICD-10-CM Official Guidelines for Coding and Reporting, which govern diagnosis code assignment.
Question 6: A patient's record shows a blood glucose of 450 mg/dL and the physician documents 'hyperglycemia.' A CDI specialist queries for diabetes mellitus with hyperglycemia. This query is appropriate because:
- The coder wants to increase the DRG weight
- Clinical indicators in the record support a more specific diagnosis (Correct answer)
- Hyperglycemia is always synonymous with diabetes
- The physician must document diabetes for billing purposes
Correct answer: Clinical indicators in the record support a more specific diagnosis
When clinical indicators such as lab values support a more specific diagnosis, a compliant query may be submitted to the physician for clarification.
RHIT Clinical Documentation Improvement 1
What is the primary goal of a Clinical Documentation Improvement (CDI) program?