Record Review and Clarification 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 Record Review and Clarification flashcards as text
Which organization's guidelines define compliant query practices for CDI professionals?
Answer: AHIMA and ACDIS joint query practice brief
AHIMA and ACDIS jointly publish the query practice brief that defines compliant CDI query standards.
A physician documents 'possible pneumonia' at discharge. Under UHDDS guidelines for inpatient coding, how should this be handled?
Answer: Code 'possible pneumonia' as if confirmed, since uncertain diagnoses are coded as confirmed for inpatient encounters
UHDDS inpatient coding guidelines allow uncertain diagnoses (possible, probable, suspected) to be coded as if confirmed at the time of discharge.
During record review, a CDI specialist finds a patient with a troponin of 2.8 ng/mL and an EKG showing ST changes, but only 'chest pain' is documented. What is the most appropriate query focus?
Answer: Query whether the patient had an acute myocardial infarction or another cardiac diagnosis
Clinical indicators such as elevated troponin and EKG changes support querying for a more specific cardiac diagnosis consistent with those findings.
Which of the following best describes the principal diagnosis for inpatient coding?
Answer: The condition established after study to be chiefly responsible for the admission
Per UHDDS, the principal diagnosis is the condition determined after study to be chiefly responsible for occasioning the admission.
A CDI specialist reviews a record where the physician documents 'MRSA infection' in a progress note but the discharge summary only lists 'staph infection.' How should this be addressed?
Answer: Query the physician to clarify the organism in the final discharge diagnosis
Conflicting documentation between notes and the discharge summary warrants a clarifying query so the physician can confirm and reconcile the final diagnosis.
What is the purpose of a 'clinical validation' query in CDI practice?
Answer: To verify that clinical evidence in the record supports a diagnosis the physician has already documented
Clinical validation queries assess whether the documented diagnosis is supported by objective clinical evidence in the record, ensuring coding accuracy and integrity.
A patient is admitted with a hip fracture and develops a hospital-acquired pressure injury during the stay. For CDI purposes, this pressure injury is classified as which type of condition?
Answer: Hospital-Acquired Condition (HAC)
Hospital-acquired pressure injuries (stage 3 or 4) are CMS-designated Hospital-Acquired Conditions, affecting POA status reporting and payment.