RHIT Clinical Documentation Improvement 3

Question 1

Which documentation is required to code a surgical complication in an inpatient record?

Accepted Answer

Physician documentation linking the condition to the surgical procedure

Answer

Any abnormal lab value post-surgery

Answer

The operative report alone

Answer

Nursing notes indicating patient discomfort

Question 2

What is the significance of 'upcoding' in clinical documentation?

Accepted Answer

It is a fraudulent practice of coding a more expensive service than documented

Answer

It is a best practice for maximizing CDI efficiency

Answer

It refers to updating outdated ICD codes to current versions

Answer

It describes querying physicians for higher-specificity diagnoses

Question 3

A CDI specialist's query response rate is 65%. What does this indicate?

Accepted Answer

65% of submitted queries received a physician response

Answer

65% of queries resulted in a diagnosis change

Answer

65% of records were queried during the month

Answer

65% of queries were submitted concurrently

Question 4

Which condition would most likely trigger a CDI query for malnutrition?

Accepted Answer

Albumin of 2.1 g/dL and physician documents only 'poor appetite'

Answer

Patient ate a full meal on day 2 of admission

Answer

Patient BMI of 22 with no dietary concerns

Answer

Patient requested a vegetarian meal tray

Question 5

What is the difference between a 'CC' and an 'MCC' in MS-DRG grouping?

Accepted Answer

CC is a complication or comorbidity; MCC is a major complication or comorbidity that has a greater impact on DRG weight

Answer

CC is a major complication; MCC is a minor complication

Answer

CC and MCC are interchangeable terms

Answer

CC applies to outpatient; MCC applies to inpatient only

Question 6

Why is it important for CDI programs to collaborate with the coding department?

Accepted Answer

To ensure documentation supports accurate code assignment and prevent denials

Answer

To reduce the number of codes assigned per record

Answer

To eliminate the need for physician queries

Answer

To bypass the official coding guidelines