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
A patient is admitted with a STEMI and undergoes PCI. The physician also documents 'systolic dysfunction' but does not specify heart failure. What CDI action is most appropriate?
Answer: Query the physician to clarify whether acute systolic heart failure is present given the STEMI and systolic dysfunction
STEMI with documented systolic dysfunction may represent acute systolic heart failure, and a query is appropriate to capture this clinically significant complication.
Which query format is generally considered the most compliant and preferred by AHIMA and ACDIS guidelines?
Answer: Multiple-choice or open-ended queries that present clinically supported diagnostic options without directing the physician to a specific answer
AHIMA and ACDIS standards require queries to be non-leading, presenting clinically supported options or leaving the answer open-ended.
In ICD-10-CM, what is the correct approach when a patient has both Type 2 diabetes and diabetic chronic kidney disease stage 4?
Answer: Use the combination code E11.22 for Type 2 diabetes with diabetic CKD and an additional code for stage 4 CKD (N18.4)
ICD-10-CM provides combination codes linking Type 2 diabetes with CKD; an additional code for the CKD stage is also assigned.
A CDI specialist reviews a record where the physician documents 'encephalopathy' without further specification in a patient with liver failure. What is the most appropriate next step?
Answer: Query the physician to clarify the type of encephalopathy (e.g., hepatic encephalopathy) to support more specific coding
Querying for specificity of encephalopathy type (e.g., hepatic vs. metabolic) ensures accurate coding, which can affect DRG assignment and severity.
When reviewing documentation for COPD patients, which finding would prompt a query for acute exacerbation vs. acute bronchitis?
Answer: Acute worsening of dyspnea, increased sputum production, and change in inhaler therapy during admission
Acute exacerbation of COPD is characterized by acute worsening of respiratory symptoms beyond normal day-to-day variation, supporting a query for clarification.
What does 'severity of illness' (SOI) measure in the context of CDI and case mix?
Answer: The degree of physiologic decompensation or organ system loss of function, typically measured by All Patient Refined DRG (APR-DRG) subclasses
SOI in APR-DRG methodology reflects physiologic decompensation levels (minor, moderate, major, extreme) and is directly influenced by diagnosis specificity.
A patient with HIV is admitted for Pneumocystis jirovecii pneumonia (PCP). How should this be coded?
Answer: Use a combination code for HIV with PCP (B20) as the principal diagnosis
ICD-10-CM uses code B20 for HIV disease, which includes all HIV-related conditions; B59 for PCP is added as an additional code.