QUESTION: 29

A patient's progress note states “The patient has chronic systolic heart failure”. After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?

The patient has decompensated systolic heart failure
The patient did have an exacerbation of heart failure
The patient has chronic systolic heart failure
The patient has acute on chronic systolic heart failure.

Answer(s): C

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QUESTION: 30

The BEST place for the provider to document a query response is which of the following?

The next progress note and all subsequent notes including the discharge summary
The query form
The next progress note and the problem list
An addendum to the history and physical

Answer(s): A

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QUESTION: 31

The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program The plan is to use case mix index (CMI) as a metric of CDI performance. How will this metric be measured?

Month-to-month and focus on patient volumes to determine the raise the overall CMI
Month-to-month to show CMI variability as a barometer of a specific month
Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI
Over time with a focus on particular documentation improvement areas in addition to the overall CMI

Answer(s): A

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