Clinical Documentation Improvement (CDI) programs can help: - answer✔✔- Build effective
documentation compliance policies
- Capture clinical data required for continuity of care
documentation deficiency that has a negative impact on patient outcomes - answer✔✔Failure to
include the complications of drug for prescriptions taken by a patient.
What is best practice to communicate document deficiencies to a provider? - answer✔✔Provide
examples of the provider's documentation errors with suggestions for improvement.
A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are found with
the diagnosis of marasmus. Your correct response: - answer✔✔Display in your query the Index
entry for marasmus and the codes and descriptions for E41 and R54. Ask for guidance on which
to report.
The best approach when querying a physician regarding documentation is to approach the
problem as one of: - answer✔✔- Evidence based medicine
- Financial motive
- Malpractice liability
- Documentation impact on reimbursement
- Documentation impact on compliance
Which EMR feature is non-compliant with CMS? - answer✔✔Templates that allow the provider
to de-select a prepopulated "normal" checkmark when the system is abnormal in the ROS
When providing CDI to a provider, does the message change depending on whether you are
performing a prospective or retrospective audit? - answer✔✔Yes, because the auditor cannot ask
leading questions regarding documentation before a claim is submitted.
What is NOT considered a purpose of documentation improvement programs? -
answer✔✔Increase reimbursements
CDI programs can help with: - answer✔✔Consistency of documentation & Team building
Which is NOT an acceptable cause for query? - answer✔✔Signs and symptoms without a
diagnosis
Which is a leading query? - answer✔✔Your sarcoidosis patient has sarcoid lesions on the
cerebral cortex, correct?
The surgeon documents liver cancer, but the pathology report states angiosarcoma of liver. You:
- answer✔✔Code the liver cancer as angiosarcoma, a primary liver cancer, based on the
pathologist's documentation.
In reviewing the provider's assessment the documentation states "lab tests reviewed: +K." You
correctly query: - answer✔✔Can you please address the patient's potassium status in further
detail?
Documentation states:
Patient has a history of a recent myocardial infarct and is admitted today with an ST elevation
MI of the anterior wall.
The flaw in this documentation from a coding standpoint: - answer✔✔The duration between the
recent myocardial infarct and the current myocardial infarct will impact coding, so "recent" is
insufficient documentation
Which term or phrase, when used between a manifestation and etiology, does NOT always show
a causal relationship? - answer✔✔likely
Which is an example of poor documentation that is especially problematic as there is no
"unspecified" code for the condition in ICD-10-CM? - answer✔✔Degenerative disc disease
(DDD)
When reviewing documentation and you notice information is missing, what is the proper
procedure? - answer✔✔The information should be added as a documented late entry/addendum
only when necessary.
Is it an acceptable practice to use a template that always documents a complete review of
systems? - answer✔✔No. The extent of ROS performed and documented is dependent upon
clinical judgment and the nature of the presenting problem(s).
Which type of documentation can be used to report diagnoses under risk adjustment models? -
answer✔✔Inpatient Admission Note
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