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
What is the primary goal of a Clinical Documentation Improvement (CDI) program in an inpatient setting?
Answer: Ensure clinical documentation accurately reflects patient severity and supports appropriate code assignment
CDI programs exist to ensure that clinical documentation fully and accurately captures patient acuity so that coding reflects the true severity of illness.
A CDI specialist issues a query to a physician about a patient with acute respiratory failure. What type of query format is generally considered compliant per AHIMA guidelines?
Answer: Open-ended query offering clinically supported options without bias
AHIMA guidelines require queries to be non-leading, offering multiple clinically supported options or an open-ended format to avoid influencing the physician's clinical judgment.
Which condition, when documented by a physician, most commonly upgrades a DRG from a lower-paying to a higher-paying MS-DRG due to MCC status?
Answer: Sepsis
Sepsis is an MCC (Major Complication or Comorbidity) that frequently causes a significant DRG upgrade when documented and coded correctly.
A CDI specialist reviews a record where the physician documents 'possible pneumonia.' How should an inpatient coder handle this?
Answer: Code pneumonia as if confirmed per UHDDS inpatient guidelines
Per UHDDS inpatient guidelines, uncertain diagnoses documented as 'possible,' 'probable,' or 'suspected' at the time of discharge are coded as if confirmed.
What does 'CC' stand for in the context of MS-DRG assignment?
Answer: Complication or Comorbidity
In MS-DRG logic, CC stands for Complication or Comorbidity, a secondary diagnosis that increases the complexity and cost of care.
Which document serves as the primary source for CDI specialists when determining whether a query is clinically supported?
Answer: The physician's progress notes, lab results, and diagnostic reports in the medical record
CDI queries must be grounded in clinical evidence found in the medical record, including progress notes, lab values, imaging, and other diagnostic data.