QUESTION: 33

The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA’s Guidelines for Achieving a Compliant Query Practice?

Complete the documentation at the time of discussion or immediately following
Complete the documentation when there is a provider agreement
Complete the documentation at the end of the day when entering cases reviewed
Complete the documentation immediately after the provider’s response

Answer(s): D

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QUESTION: 34

An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray. Intravenous antibiotics were administered, and the pneumonia was monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1 Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

553 Bone Diseases and Arthropathies with MCC
179 Respiratory Infections and Inflammations without CC/MCC
470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
469 Major Joint Replacement or Reattachment of Lower Extremity with MCC

Answer(s): D

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QUESTION: 35

A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101° Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents “right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis”. What is the proper sequencing of the principal and secondary diagnoses?

Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis
Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus
Right lower quadrant abdominal pain, fever, vomiting, leukocytosis
Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus

Answer(s): B

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QUESTION: 36

A 70-year-old severely malnourished nursing home patient is admitted for a pressure ulcer covered by eschar on the right hip. The provider is queried to clarify the stage of the pressure ulcer. Because the wound has not been debrided, the provider responds “unable to determine”. How will the stage of this pressure ulcer be coded?

Undetermined stage pressure ulcer
Unstageable pressure ulcer
Stage III pressure ulcer
Stage IV pressure ulcer

Answer(s): B

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