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 program is implementing risk adjustment-focused outpatient reviews. Which approach is most effective for condition capture?
Answer: Focus on patients with known chronic conditions whose annual wellness visits are approaching
Targeting patients with chronic conditions around annual wellness visits maximizes impact with focused resources.
A provider documents 'dementia' in a 78-year-old patient. Which CDI query elements are essential?
Answer: Dementia type, etiology, and any behavioral disturbances
The query should address type, etiology, and behavioral disturbances. Dementia with behavioral disturbance maps to a higher-severity HCC.
The discharge summary says 'acute kidney injury' while the nephrology consultation documents 'acute on chronic kidney disease stage 3.' Which documentation should drive CDI action?
Answer: A CDI query should reconcile the conflicting documentation
Conflicting documentation requires reconciliation by the attending physician.
A CDI team is measuring financial impact of their risk adjustment program. Which metric best demonstrates value?
Answer: Net RAF score change attributable to CDI-identified improvements
Net RAF score change directly quantifies financial impact and can be converted to dollar impact.
In which scenario is retrospective CDI review more appropriate than concurrent review?
Answer: When analyzing prior year encounter data to identify systematic documentation gaps
Retrospective CDI is most appropriate for analyzing historical data to identify systematic patterns and inform future documentation improvement.
Which principle should be emphasized as the foundation of all CDI activities?
Answer: Ensuring documentation accurately reflects the patient's true clinical complexity
The foundation of CDI must be clinical accuracy, not revenue optimization. This ensures compliance and quality of care.