QUESTION: 25

The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate. What might this indicate to the CDI manager?

The loss of a large volume of patients has impacted workflow
CDI staff need education on identifying query opportunities
The program is successful because documentation has improved
The decrease in hospital census has caused a lack of query opportunities

Answer(s): B

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Several physicians at a local hospital are having difficulty providing adequate documentation on patients admitted with a diagnosis of pneumonia with or without clinical indications of gram-negative pneumonia. Subsequently, clinical documentation integrity practitioners (CDIPs) are altering health records. Which policy and procedure should be developed to ensure compliant practice?

Performance standards
Quality improvement standards
Accreditation standards
Professional ethical standards

Answer(s): D

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QUESTION: 27

The facility has received a clinical validation denial for sepsis. The denial states sepsis is not a clinically valid diagnosis because it does not meet Sepsis-3 criteria. The facility has a policy stating it uses Sepsis-2 criteria. What is the BEST next step?

Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.
Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.
Appeal the denial because all payors must use the hospital's sepsis criteria when reviewing their claims.
Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.

Answer(s): D

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QUESTION: 28

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)?

Query for malignant pleural effusion
Query for a diagnosis associated with the dietician’s finding of malnutrition
Query if the malignant pleural effusion is the reason for admission
Query for protein calorie malnutrition

Answer(s): B

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QUESTION: 25

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QUESTION: 28

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