A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician's documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit. Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD. Discharge diagnoses:
1.
Pneumonia
2.
COPD
3.
Current smoker
What is the correct diagnostic related group assignment?
A. DRG 190 Chronic Obstructive Pulmonary Disease with MCC
B. DRG 202 Bronchitis and Asthma with CC/MCC
C. DRG 204 Respiratory Signs and Symptoms
D. DRG 194 Simple Pneumonia and Pleurisy without CC/MCC
Correct Answer: A
According to the ICD-10-CM/PCS MS-DRG Definitions Manual, DRG 190 is assigned for patients with a principal diagnosis of chronic obstructive pulmonary disease (COPD) and a major complication or comorbidity (MCC)1. Pneumonia is considered an MCC for this DRG2. Therefore, the patient in this case meets the criteria for DRG 190. The other options are incorrect because they do not match the principal diagnosis or the MCC of the patient. References: ICD-10-CM/PCS MS-DRG Definitions Manual ICD-10-CM/PCS MS-DRG v38.0 Definitions Manual - MDC 4: Diseases and Disorders of the Respiratory System
Question 82:
When benchmarking with outside organizations, the clinical documentation integrity practitioner (CDIP) must determine if the organization is benchmarking with which of the following criteria?
A. Hospital within its region
B. Hospitals that are its peers
C. Hospital within its county
D. Hospital within its state
Correct Answer: B
When benchmarking with outside organizations, the clinical documentation integrity practitioner (CDIP) must determine if the organization is benchmarking with hospitals that are its peers because peer hospitals have similar characteristics
such as size, location, teaching status, case mix index, and payer mix. Benchmarking with peer hospitals allows for a more accurate and meaningful comparison of performance indicators and outcomes.
(CDIP Exam Preparation Guide)
References:
CDIP ontent Outline1
CDIP Exam Preparation Guide2
Question 83:
A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?
A. No query is needed
B. Query physician for POA
C. Bring this case up in weekly Health Information Management meetings for further action
D. Take the case to physician advisor/champion to discuss further action
Correct Answer: B
A query should be generated to ask the physician for the POA indicator of the fall because the documentation is unclear whether the fall was present at the time of inpatient admission or not. The POA indicator is used to identify conditions that are present or not present at the time of admission, and has payment implications for certain hospital-acquired conditions (HACs). According to CMS, a fall resulting in trauma is one of the HACs that will not be paid at a higher rate if it is not present on admission. Therefore, it is important to clarify the POA indicator of the fall to ensure accurate coding and reimbursement. A query should be non-leading, concise, clear, relevant, and consistent with CDI standards and guidelines. References: CDIP?ontent Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf) Coding | CMS1 Present on Admission Indicators - Novitas Solutions2
Question 84:
Whether or not queries should be kept as a permanent part of the medical record is decided by
A. physician preference
B. state law
C. federal law
D. organizational policy
Correct Answer: D
According to the AHIMA/ACDIS Query Practice Brief, whether or not queries should be kept as a permanent part of the medical record is decided by the organizational policy of each facility1. There is no federal or state law that mandates the retention of queries in the medical record, although some external reviewers may request copies of queries to validate the query wording and compliance2. Physician preference is not a valid factor in determining the query retention policy, as queries should be handled consistently across the organization3. Therefore, the correct answer is D. organizational policy. References: Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA QandA: Develop policies regarding query retention | ACDIS QandA: Keep query retention policies consistent | ACDIS
Question 85:
What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?
A. Multiple-choice
B. Open-ended
C. Verbal
D. Yes/No
Correct Answer: D
A yes/no query may not be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record because it may lead to leading or suggesting a diagnosis that is not supported by the provider's documentation. A yes/no query should only be used when there is clear and consistent documentation of a condition/diagnosis in the health record, and the query is seeking confirmation or denial of a specific fact or detail related to that condition/diagnosis. A multiple-choice, open-ended, or verbal query may be more appropriate to allow the provider to choose from a list of possible diagnoses, provide additional information, or explain the clinical reasoning behind the documentation. (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2 AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3
Question 86:
A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?
A. Look for wound care documentation
B. Read the nursing admission notes
C. Query the attending provider
D. Review the history and physical
Correct Answer: D
The first step that a clinical documentation integrity practitioner (CDIP) should take to determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary is to review the history and physical (HandP) because it is the initial source of information about the patient's condition at the time of admission. The HandP should include a comprehensive physical examination that covers all body systems, including the skin. If the HandP documents the presence of a stage IV sacral decubitus ulcer, then the POA status is "yes". If the HandP does not mention the ulcer, then the CDIP should look for other sources of documentation, such as wound care notes, nursing notes, or progress notes, to see if the ulcer was identified or treated during the hospital stay. If there is no clear evidence of when the ulcer developed, then the CDIP should query the attending provider to clarify the POA status. (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2 Present on Admission Reporting Guidelines3
Question 87:
Which member of the clinical documentation integrity (CDI) team can help provide peer-to- peer level of education on the importance of accurate documentation and query responses?
A. Chief Financial Officer
B. Physician advisor/champion
C. CDI practitioner
D. CDI manager
Correct Answer: B
The member of the clinical documentation integrity (CDI) team who can help provide peer- to-peer level of education on the importance of accurate documentation and query responses is the physician advisor/champion. The physician advisor/champion is a physician who supports and advocates for the CDI program and its goals, and who can communicate effectively with other physicians about the clinical and financial implications of documentation quality and accuracy. The physician advisor/champion can also serve as a liaison between the CDI team and the medical staff, and help to resolve any issues or conflicts that may arise from the query process. The physician advisor/champion can also provide feedback and guidance to the CDI team on clinical matters and documentation standards. (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2
Question 88:
A key physician approaches the director of the coding department about the new emphasis associated with clinical documentation integrity (CDI). The physician does not support the program and believes the initiative will encourage inappropriate billing.
How should the director respond to the concerns?
A. Develop an administrative panel to oversee CDI process
B. Refer the physician to the finance department to discuss required billing changes
C. Involve the physician advisor/champion in addressing the medical staff's concerns
D. Inform the physician that changes must be made
Correct Answer: C
The director should involve the physician advisor/champion in addressing the medical staff's concerns because the physician advisor/champion is a key member of the CDI team who can provide clinical expertise, education, and leadership to
promote CDI among physicians. The physician advisor/champion can help to explain the goals and benefits of CDI, such as improving patient care quality, accuracy of documentation, and appropriate reimbursement. The physician advisor/
champion can also address any misconceptions or fears that the physicians may have about CDI, such as encouraging inappropriate billing or increasing their workload. The physician advisor/champion can serve as a liaison between the CDI
team and the medical staff, and foster a culture of collaboration and trust.
A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?
A. Any physician caring for the patient can correct inaccurate record notes
B. Errors are corrected by the clinician who authored the documentation
C. Amendments to record content must be co-signed by the attending physician
D. Coders can rely on the laboratory results to confirm the patient's diagnosis
Correct Answer: B
According to AHIMA, best practice for fixing a mistake in a patient health record is that errors are corrected by the clinician who authored the documentation1. The clinician who made the error should identify and correct the inaccurate information, and document the date, time, and reason for the correction1. The correction should also be made in a way that preserves the original content and does not obscure or delete it1. The other options are not correct according to AHIMA. Any physician caring for the patient cannot correct inaccurate record notes, as this may compromise the accountability and integrity of the documentation2. Amendments to record content do not need to be co-signed by the attending physician, unless required by organizational policy or state law3. Coders cannot rely on the laboratory results to confirm the patient's diagnosis, as they should code based on the physician's documentation and not on test results alone. References: Making Corrections in the Electronic Health Record - AHIMA Auditing Copy and Paste - AHIMA Amendments, Corrections, and Deletions in Transcribed Reports Toolkit - AHIMA [Coding from Test Results | Journal Of AHIMA]
Question 90:
Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?
A. Legible
B. Complete
C. Reliable
D. Precise
Correct Answer: C
According to AHIMA, clinical documentation is at the core of every patient encounter and it must be meaningful to accurately reflect the patient's disease burden and scope of services provided. In order to be meaningful, the documentation
must be clear, consistent, complete, precise, reliable, timely, and legible1. Reliability is one of the criteria for clinical documentation that means the content of the record is trustworthy, safe, and yielding the same result when repeated1.
Reliability ensures that the documentation is consistent with the clinical evidence and reasoning, and that it can be verified by other sources or methods. Reliability also implies that the documentation is free from errors, omissions,
contradictions, or ambiguities that could compromise its validity or usefulness1.
References:
Clinical Documentation Integrity Education and Training | AHIMA1
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