Clinical Knowledge and Documentation Guidelines Flashcards
7 cards from real CDIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Clinical Knowledge and Documentation Guidelines flashcards as text
When a patient is admitted with decompensated heart failure and also has stage 3 chronic kidney disease, how should the CDI specialist approach querying for a relationship between the two conditions?
Answer: Query the physician if clinical indicators suggest a pathophysiological relationship even without explicit documentation
CDI specialists should query when clinical indicators support a pathophysiological relationship, as the physician must establish and document any causal link.
Which of the following best describes 'clinical validation' in the context of CDI?
Answer: Verifying that documented diagnoses are supported by clinical evidence in the medical record
Clinical validation confirms that diagnoses documented by the physician are substantiated by objective clinical findings, lab values, and other evidence.
A patient's lab results show a serum lactate of 4.2 mmol/L and blood cultures are positive. The physician documents 'sepsis.' What additional documentation query may be appropriate?
Answer: Query to clarify whether septic shock or organ dysfunction is present given the lactate elevation
An elevated lactate ≥2 mmol/L with sepsis may indicate septic shock per Sepsis-3 criteria, warranting a query for clarification.
Under ICD-10-CM guidelines, when two or more diagnoses equally meet the definition of principal diagnosis, what should guide final code selection?
Answer: Either condition may be sequenced first, guided by the attending physician's preference or coding guidelines
When two conditions equally qualify as principal diagnosis, ICD-10-CM guidelines allow either to be sequenced first, and physician or coder judgment applies.
A patient is admitted for a hip fracture following a mechanical fall. Which documentation element is most critical for accurate coding of the fracture?
Answer: Laterality, fracture type, and whether it is an initial encounter, subsequent, or sequela
ICD-10-CM fracture codes require specificity including laterality, fracture type, and encounter type (initial, subsequent, or sequela).
Which clinical indicator most strongly supports querying a physician to add 'acute respiratory failure' as a secondary diagnosis in a COPD exacerbation patient?
Answer: PaO2 of 55 mmHg on arterial blood gas with oxygen therapy initiated
A PaO2 of 55 mmHg meets objective criteria for hypoxemic respiratory failure and strongly supports a query for acute respiratory failure.
When querying for malnutrition in a hospitalized patient, which set of criteria is most commonly referenced?
Answer: ASPEN/AND malnutrition consensus criteria including energy intake, weight loss, and loss of muscle mass
The ASPEN/AND 2012 consensus criteria are the standard used in clinical practice and CDI to support documentation of malnutrition.