Clinical Documentation Improvement Flashcards
6 cards from real CRC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Clinical Documentation Improvement flashcards as text
A CDI specialist reviews a chart where the physician documents 'CHF' without further specification. Which query would be most effective for risk adjustment?
Answer: What is the heart failure type, acuity, and current severity class?
An effective CDI query should address all specificity elements: type, acuity, and severity. This avoids multiple follow-ups.
A CDI specialist notices lab values showing eGFR of 22 mL/min but the physician only documents 'renal insufficiency.' What is the appropriate CDI action?
Answer: Query the provider to document CKD stage consistent with the eGFR findings
CDI specialists cannot diagnose based on lab values alone. The appropriate action is to query the provider to document the CKD stage.
A physician documents 'patient is malnourished.' The dietitian's assessment documents 'severe protein-calorie malnutrition with BMI 15.2.' For CDI purposes, which source can be used?
Answer: A CDI query should be generated for the physician to confirm the severity
Best practice for risk adjustment is to have the physician document or confirm the severity, creating the strongest documentation for RADV audit defense.
A CDI team finds query response rate dropped from 85% to 60%. Which strategy is most likely to improve physician engagement?
Answer: Redesign queries to be more specific with clinical indicators and response checkboxes
Improving query design with specific clinical indicators and easy response formats is the most effective strategy.
Which documentation improvement scenario would have the greatest positive impact on risk adjustment accuracy?
Answer: Changing 'diabetes' to 'diabetes mellitus type 2 with diabetic nephropathy' when supported by evidence
Specifying diabetes type and capturing complications directly affects HCC mapping. Diabetes with nephropathy maps to HCC 18, nearly tripling the RAF contribution vs diabetes alone.
A CDI specialist finds a patient admitted for pneumonia also has chronic respiratory failure with home oxygen documented on the problem list but not addressed in the current encounter. What action is appropriate?
Answer: Query the provider to address the chronic respiratory failure in the current encounter
For risk adjustment, conditions must be documented as actively addressed in the current encounter, not just present on a problem list.