CIC Clinical Documentation Improvement Flashcards
6 cards from real CIC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CIC Clinical Documentation Improvement flashcards as text
When a physician documents 'malnutrition' without further specification, what should a CDI specialist do to optimize coding accuracy?
Answer: Query the physician to clarify the type and severity of malnutrition (e.g., mild, moderate, severe)
Malnutrition severity (mild, moderate, severe) significantly impacts DRG assignment, so CDI specialists should query for specificity when documentation is vague.
What is the significance of the 'present on admission' (POA) indicator in inpatient coding?
Answer: It identifies whether a condition existed at the time of inpatient admission, affecting hospital-acquired condition reporting
The POA indicator differentiates conditions present at admission from those that developed during the hospital stay, which is critical for hospital-acquired condition (HAC) reporting and payment penalties.
A physician's discharge summary documents 'UTI' but lab results show E. coli bacteremia. What should the CDI specialist do?
Answer: Query the physician about whether the bacteremia should be documented and coded separately
When clinical findings such as lab results are not addressed in the physician's documentation, CDI specialists should query the physician rather than code directly from lab data alone.
Which of the following best describes a 'retrospective CDI query'?
Answer: A query issued after the patient has been discharged to clarify documentation for coding
Retrospective queries are issued after patient discharge when documentation gaps or ambiguities are discovered during the coding process.
Under AHIMA's CDI query guidelines, which of the following is NOT an appropriate reason to issue a physician query?
Answer: To increase reimbursement for a diagnosis not supported by clinical evidence
Queries must be clinically supported and cannot be issued solely to increase reimbursement without corresponding clinical evidence, as this would violate compliance standards.
What coding guideline applies when a patient is admitted for a condition that is a complication of a previous procedure?
Answer: Code the complication as the principal diagnosis if it meets the UHDDS definition
If a complication of a prior procedure is the condition established after study as chiefly responsible for the admission, it should be coded as the principal diagnosis per UHDDS guidelines.