Which of the following is the definition of an Excludes 2 note in ICD-10-CM?
A. Neither of the codes can be assigned
B. Two codes can be used together to completely describe the condition
C. Only one code can be assigned to completely describe the condition
D. This is not a convention found in ICD-10-CM
Correct Answer: B
An Excludes 2 note in ICD-10-CM indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes 2 note appears under a code, it is
acceptable to use both the code and the excluded code together to completely describe the condition. For example, under code R05 Cough, there is an Excludes 2 note for whooping cough (A37.-). This means that a patient can have both a
cough and whooping cough at the same time, and both codes can be used together to capture the full clinical picture.
ICD-10-CM Features | Diagnosis Coding: Using the ICD-10-CM1
Question 12:
The BEST place for the provider to document a query response is which of the following?
A. The query form
B. The next progress note and the problem list
C. The next progress note and all subsequent notes including the discharge summary
D. An addendum to the history and physical
Correct Answer: B
The best place for the provider to document a query response is the next progress note and the problem list because this ensures that the query response is timely, consistent, and integrated into the health record. According to the AHIMA/
ACDIS query practice brief1, the provider should document the query response in the health record as soon as possible after receiving the query, preferably in the next progress note. The provider should also update the problem list to reflect
any new or revised diagnoses resulting from the query response. This helps to maintain an accurate and comprehensive list of the patient's current and chronic conditions, which can facilitate continuity of care, quality reporting, and
reimbursement. Documenting the query response in an addendum to the history and physical or only on the query form is not sufficient, as it may not capture the current status of the patient or be easily accessible to other providers or coders.
Guidelines for Achieving a Compliant Query Practice--2022 Update1
Question 13:
A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side. The default code is
A. ambidextrous
B. non-dominant
C. preferred
D. dominant
Correct Answer: B
According to the ICD-10-CM Official Guidelines for Coding and Reporting, when the affected side is not documented for a condition that is commonly associated with hemiplegia or hemiparesis, such as a cerebral vascular accident, the default code is the non-dominant side. The non-dominant side is usually the left side for right-handed individuals and the right side for left-handed individuals. However, if the patient is ambidextrous, the default code is still the non-dominant side, unless the provider indicates otherwise. Therefore, in this case, the default code for cerebral vascular accident with left sided weakness is I63.532 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery1. References: CDIP?ontent Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf) ICD-10 Code for Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery- I63.532- AAPC Coder1 ICD-10-CM Official Guidelines for Coding and Reporting FY 2022
Question 14:
A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?
A. Physician's Desk Reference
B. Medical Dictionary
C. The Merck Manual
D. AMA CPT Assistant
Correct Answer: C
The reference resource that should be used to obtain information about the signs and symptoms that are inherent to asthma is The Merck Manual. This is a comprehensive medical reference that covers various topics related to diseases, diagnosis, treatment, and prevention. The Merck Manual provides a detailed description of asthma, including its causes, risk factors, pathophysiology, clinical features, diagnosis, management, and complications. According to The Merck Manual, the signs and symptoms that are inherent to asthma are wheezing, coughing, chest tightness, and dyspnea (shortness of breath) 2. These symptoms are caused by the reversible bronchoconstriction and inflammation of the airways that characterize asthma. The Merck Manual also explains how these symptoms can be triggered or exacerbated by various factors, such as allergens, infections, exercise, cold air, stress, or medications 2. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: Asthma - Pulmonary Disorders - Merck Manuals Professional Edition 4
Question 15:
Review the following query to determine if it is compliant:
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Dehydration
Hyponatremia
Hypernatremia
Chronic kidney disease (indicate stage)
Other (please specify)
A. Yes, query is compliant as it offers the minimum number of multiple-choice answers ..
B. No, query is noncompliant as it does not provide the option of "unable to determine".
C. No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.
D. Yes, query is compliant as it provides clinical indicators and several options for response.
Correct Answer: C
A query is noncompliant if it includes options that are not supported by the clinical indicators or the patient's condition. In this case, hypernatremia is a condition of high sodium level, not low sodium level, and it is not consistent with the treatment of 0.9% saline IV. Therefore, it is a clinically irrelevant option that may confuse or mislead the provider. A compliant query should only include options that are reasonable and plausible based on the available documentation and evidence. (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2 AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3
Question 16:
Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?
A. Chief Medical Officer
B. Compliance Officer
C. CDI practitioner
D. Chief Financial Officer
Correct Answer: A
The clinical documentation integrity (CDI) manager should consult the Chief Medical Officer when developing query policy and procedures because the Chief Medical Officer is responsible for overseeing the quality and safety of patient care, ensuring compliance with regulatory and accreditation standards, and providing leadership and guidance to the medical staff. The Chief Medical Officer can help to establish the goals, scope, and authority of the CDI program, as well as to support the query process and promote provider education and engagement. (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2
Question 17:
A noncompliant query includes querying the provider regarding
A. acute blood loss anemia due to low hemoglobin treated with iron supplements
B. sepsis that was present on admission because sepsis was only documented in the discharge summary
C. gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators
D. morbid obesity due to BMI of 40.9 documented on the history and physical
Correct Answer: C
A noncompliant query includes querying the provider regarding gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators because it may lead to over-specification of a diagnosis that is not supported by the health record. A compliant query should be based on the clinical evidence and documentation in the record, and should not suggest or imply a diagnosis that is not clinically relevant or plausible. A query should also not be driven by reimbursement or coding factors, but by the need to improve the quality and accuracy of documentation. (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2 Guidelines for Achieving a Compliant Query Practice (2019 Update)3
Question 18:
A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy 3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19. Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?
A. Query for protein calorie malnutrition
B. Query for malignant pleural effusion
C. Query for a diagnosis associated with the dietician's finding of malnutrition
D. Query if the malignant pleural effusion is the reason for admission
Correct Answer: B
According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non- leading query statement2. In this case, the patient has a large right lung pleural effusion related to lung cancer stage II, which is documented multiple times. However, the documentation does not specify whether the pleural effusion is malignant or not. A malignant pleural effusion is a condition where cancer cells spread to the pleural space and cause fluid accumulation3. A malignant pleural effusion is a major complication or comorbidity (MCC) that affects the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality scores of the hospital4. Therefore, a post discharge query opportunity should be sent to the physician to clarify whether the pleural effusion is malignant or not, based on the clinical indicators such as chest x-ray, thoracentesis, and fluid analysis. The query should provide answer options such as malignant pleural effusion, non-malignant pleural effusion, unable to determine, or other. The other options are not correct because they either do not affect the SOI/ROM of the patient (A and C), or they do not address the specificity of the diagnosis (D). References: CDIP Exam Preparation Guide - AHIMA Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Malignant Pleural Effusion: Symptoms, Causes, Diagnosis and Treatment QandA: Coding for malignant pleural effusions | ACDIS
Question 19:
A 75-year-old, diabetic patient with a history of osteoporosis, being treated with Fosamax, who sustained a femur fracture after falling down three stairs. The provider's documentation indicates to admit the patient for a traumatic femur fracture and an orthopedics consult is pending. The clinical documentation integrity practitioner (CDIP) decides to query for a possible link between osteoporosis and the femur fracture. Which of the following is the most compliant query based on the most recent
AHIMA/ACDIS query practice brief?
A. Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. In your medical opinion, is this fracture consistent with an osteoporotic pathological fracture?
B. Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please clarify the cause of the femur fracture in your next note and/or the discharge summary.
C. Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Could diabetes be a contributing factor in the femur fracture?
D. Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please document "femur fracture due to osteoporosis" in your next progress note to demonstrate a link between the two diagnoses.
Correct Answer: A
This query option is the most compliant based on the most recent AHIMA/ACDIS query practice brief because it meets the following criteria:
It is based on clinical indicators in the health record that support a reasonable and logical connection between the conditions (femur fracture and osteoporosis). It is non-leading and non-suggestive, as it does not imply a specific answer or
diagnosis, but rather asks for the provider's opinion based on their clinical judgment.
It is concise and clear, as it uses simple and direct language that avoids ambiguity or confusion.
It is relevant and specific, as it addresses a clinical issue that has an impact on patient care, quality reporting, and/or reimbursement. It is consistent with clinical documentation integrity (CDI) standards and guidelines, as it follows the AHIMA/
ACDIS query practice brief recommendations for query format, content, delivery, and documentation.
CDIP?Exam Preparation Guide (https://my.ahima.org/store/product?id=67077) Guidelines for Achieving a Compliant Query Practice--2022 Update (https://acdis.org/resources/guidelines-achieving-compliant-query- practice%E2%80%942022update)
Question 20:
Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include
A. performing data analysis
B. developing query forms
C. educating physicians
D. querying physicians
Correct Answer: C
Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include educating physicians on the importance and impact of clinical documentation on coding, reimbursement,
quality measures, compliance, and patient care. The physician advisor/champion can act as a liaison between the CDIPs and the medical staff, provide feedback and guidance on query development and resolution, and facilitate peer-to-peer
education sessions on documentation best practices and standards6 References: 1:
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