CDIP Clinical Validation Principles 2

Question 1

A physician documents 'acute kidney injury' in a patient with a creatinine of 1.2 mg/dL (baseline 1.0).
A CDI specialist reviews the record and finds no clinical indicators supporting AKI.
What is the most appropriate action?

Accepted Answer

Query the physician to clarify if clinical indicators support the AKI diagnosis

Answer

Accept the diagnosis as documented without question

Answer

Change the diagnosis to 'abnormal creatinine' without querying

Answer

Ignore the documentation and code based on lab values alone

Question 2

Which organization's 'Coding Clinic' guidance is the authoritative source for ICD-10-CM/PCS coding advice that CDI specialists must follow?

Accepted Answer

American Hospital Association (AHA)

Answer

Centers for Medicare & Medicaid Services (CMS)

Answer

American Health Information Management Association (AHIMA)

Answer

The Joint Commission (TJC)

Question 3

When performing clinical validation of a sepsis diagnosis, which set of criteria is most commonly referenced to determine clinical support?

Accepted Answer

SOFA/qSOFA and Sepsis-3 definitions

Answer

Ranson's criteria

Answer

Child-Pugh score

Answer

APACHE II score alone

Question 4

A CDI specialist disagrees with a physician's documented diagnosis based on clinical indicators. After querying, the physician affirms the diagnosis. What should the CDI specialist do?

Accepted Answer

Accept the physician's clinical judgment and document the query outcome

Answer

Escalate to the compliance department to override the physician

Answer

Submit the case to the coding team to code a different diagnosis

Answer

Remove the query from the record

Question 5

Which of the following best describes the concept of 'clinical criteria' in the context of clinical validation?

Accepted Answer

Signs, symptoms, lab results, imaging, and treatment that collectively support a diagnosis

Answer

Only laboratory values that confirm a diagnosis

Answer

The physician's subjective impression documented in the assessment

Answer

Diagnostic codes assigned by the coding team

Question 6

A hospital implements a clinical validation program that results in frequent downgrades of diagnoses. Which risk does this primarily expose the hospital to?

Accepted Answer

Potential allegations of improper denial of legitimate diagnoses and upcoding in reverse

Answer

Increased DRG weight and higher reimbursement

Answer

Reduced physician satisfaction only

Answer

Improved accuracy with no compliance risk

Question 7

Which document type is NOT an appropriate reference source for clinical validation of a malnutrition diagnosis?

Accepted Answer

Insurance company's prior authorization denial letter

Answer

Dietitian's nutritional assessment note

Answer

Physician's history and physical

Answer

Nursing intake and output documentation