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
A CDI specialist reviews a record where the attending documents 'sepsis' but the blood cultures are negative and antibiotics were discontinued after 48 hours. What is the most appropriate action?
Answer: Query the physician asking whether sepsis or an alternative diagnosis better reflects the clinical picture
When clinical indicators don't fully support a documented diagnosis, a compliant query seeking clarification of the most accurate diagnosis is appropriate.
Which type of query format presents a list of diagnosis options based on clinical indicators and asks the physician to select, add, or indicate 'none of the above'?
Answer: Multiple-choice query
A multiple-choice query offers clinically supported options and a 'none of the above' choice to remain compliant and non-leading.
A query is sent regarding a patient with a BMI of 42 and documentation of 'overweight.' The physician does not respond. How should the CDI specialist proceed?
Answer: Leave the query open and follow up per facility policy
Unanswered queries should be followed up according to facility policy; coders cannot assign a diagnosis absent physician documentation.
During concurrent review, a CDI specialist notes a patient is receiving IV insulin drip and frequent glucose checks but 'diabetes' is not documented. What is the best approach?
Answer: Query the physician to clarify whether a diabetic condition exists
Concurrent CDI review allows timely queries so physicians can clarify diagnoses before discharge, improving accuracy.
Which statement best describes a 'leading' query and why it is non-compliant?
Answer: It suggests a specific diagnosis without adequate clinical basis, influencing the physician's response inappropriately
A leading query steers the physician toward a specific, often higher-reimbursing diagnosis without sufficient clinical justification, violating query integrity standards.
A patient's record documents 'acute renal failure' on admission but the final diagnoses list only 'chronic kidney disease stage 3.' What should the CDI specialist do?
Answer: Query the physician to clarify whether acute-on-chronic kidney disease or AKF resolved should be documented
Discrepancies between admission documentation and discharge summary warrant a clarifying query to ensure accurate final coding.
Post-discharge retrospective queries are considered appropriate in which scenario?
Answer: When a clinical indicator was present during the stay but the opportunity was missed during concurrent review
Retrospective queries are appropriate when a legitimate documentation gap existed during the encounter that was not addressed concurrently.