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When there is a discrepancy between the clinical documentation integrity practitioner’s (CDIP’s) working DRG and the coder’s final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?

  1. Physician and CDIP interaction
  2. Coder and CDIP interaction
  3. Physician advisor/champion involvement
  4. Executive oversight

Answer(s): B



A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient’s diagnosis. Which response provides the highest level of specificity?

  1. Acute CHF with hypertensive renal disease, CKD 3
  2. Acute diastolic CHF with HTN and CKD 3
  3. Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
  4. Acute on chronic systolic CHF with hypertensive renal disease, CKD 3

Answer(s): C



Which of the following is nonessential to facilitate code capture when educating clinical staff on documentation practices associated with diabetes mellitus?

  1. Manifestation
  2. Type
  3. Age
  4. Cause

Answer(s): D



A query should be generated when the documentation is

  1. consistent
  2. legible
  3. conflicting
  4. complete

Answer(s): C






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