CDIP Practice Exam Questions with Answers Certified Documentation Integrity Practitioner Certification

A noncompliant multiple-choice query is one that does not include at least four options because it may limit the provider’s choice and suggest a preferred answer. A compliant multiple-choice query should include at least four options that are clinically significant, reasonable, and plausible based on the clinical indicators and documentation in the health record. The options should also be listed in alphabetical order to avoid any bias or preference. A compliant multiple-choice query should also allow the provider to add their own response if none of the options are appropriate, and include the option of “unable to determine” if the provider cannot make a definitive diagnosis based on the available information. (CDIP Exam Preparation Guide)

References:

• CDIP Exam Content Outline1
• CDIP Exam Preparation Guide2
• Guidelines for Achieving a Compliant Query Practice (2019 Update)3

Hospital-acquired condition pay provisions apply only to inpatient prospective payment system hospitals because they are subject to the CMS policy that reduces payments for cases with conditions that were not present on admission. This policy is intended to encourage hospitals to improve the quality of care and prevent avoidable complications. Other types of hospitals, such as critical access hospitals, long-term acute care hospitals, and inpatient psychiatric hospitals, are not affected by this policy and are paid based on different methodologies. (CDIP Exam Preparation Guide)

References:

• CDIP Exam Content Outline1
• CDIP Exam Preparation Guide2
• Hospital-Acquired Conditions (Present on Admission Indicator): Hospital …3

According to the CPT code description, 61154 is the appropriate code for a burr hole procedure for evacuation of a subdural hematoma. A burr hole is a small hole made in the skull with a surgical drill to access the brain or its coverings2. A subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, which are two of the three layers that cover the brain3. The evacuation of the hematoma involves removing the clot and relieving the pressure on the brain. The other codes are not applicable for this procedure because they describe different methods of access (twist drill hole) or different purposes (biopsy or puncture)4.

References:

• CDI Week 2020 Q&A: CDI and key performance indicators1
• Mayo Clinic: Burr hole2
• MedlinePlus: Subdural hematoma3
• CPT Code Book 20234

According to the AHIMA CDIP Exam Preparation Guide, a modifier is a two-digit numeric or alphanumeric code that may be used in CPT and/or HCPCS codes to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code1. One of the reasons to use a modifier is to indicate that a service or procedure was increased or reduced in comparison to the usual service or procedure2. For example, modifier 22 can be used to report increased procedural services that require substantially greater time, effort, or complexity than the typical service3. The other options are not correct because they do not reflect the purpose of using modifiers. A service or procedure performed in its entirety does not need a modifier, as it is assumed to be the standard service or procedure. A service or procedure resulting in expected outcomes does not affect the coding or reimbursement of the service or procedure. A service or procedure performed by one provider may need a modifier depending on the type of provider, the place of service, and the payer rules, but it is not a general reason to use a modifier. References:

• CDIP Exam Preparation Guide - AHIMA
• Modifiers: A Guide for Health Care Professionals - CMS
• CPT® Modifiers: 22 Increased Procedural Services | AAPC

An open-ended query is a type of query that allows the provider to respond with free text, rather than choosing from a list of options or answering yes or no. An open-ended query is appropriate when the CDIP is looking for clarity on whether a diagnosis has been “ruled in” or “ruled out”, because it allows the provider to document the final diagnosis or impression based on the clinical evidence and reasoning. An open-ended query also avoids leading or suggesting a specific diagnosis to the provider, which could compromise the integrity and validity of the documentation. (Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1)

References:

• Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1

A query is noncompliant if it includes options that are not supported by the clinical indicators or the patient’s condition. In this case, hypernatremia is a condition of high sodium level, not low sodium level, and it is not consistent with the treatment of 0.9% saline IV. Therefore, it is a clinically irrelevant option that may confuse or mislead the provider. A compliant query should only include options that are reasonable and plausible based on the available documentation and evidence. (CDIP Exam Preparation Guide)

References:

• CDIP Exam Content Outline1
• CDIP Exam Preparation Guide2
• AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3

The clinical documentation integrity practitioner (CDIP) should interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC) by asking the physician to indicate if the pneumonia was present on admission (POA) based on the initial chest x-ray. This is because the POA status of a condition affects its coding, reporting, and reimbursement, and it is the responsibility of the physician to document the POA status of all diagnoses. The CDIP should not assume that the pneumonia developed after admission based on the timing of symptoms or treatment, as this may not reflect the true clinical picture. The CDIP should also not ask the physician about the causal relationship between the acute kidney injury and the pneumonia, as this is not relevant to the POA status. The CDIP should also not avoid querying the physician based on the presence of another MCC, as this may compromise the accuracy and completeness of documentation. (CDIP Exam Preparation Guide)

References:

• CDIP Exam Content Outline
• CDIP Exam Preparation Guide
• Present on Admission Reporting Guidelines

An outstanding query may result in an incomplete health record deficiency being assigned to a provider, if the query is not answered or resolved before the discharge or final coding of the patient. An outstanding query is a query that has been generated by the clinical documentation integrity practitioner (CDIP) or the coder, but has not been acknowledged or addressed by the provider. An outstanding query may affect the accuracy and completeness of the health record, as well as the coding, reimbursement, quality measures, and compliance of the hospital. References: : https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf : https://my.ahima.org/store/product?id=67077

Levophed is a brand name of norepinephrine, a medication that is similar to adrenaline and acts as a vasopressor, meaning that it constricts blood vessels and increases blood pressure. Levophed is indicated to raise blood pressure in adult patients with severe, acute hypotension (low blood pressure) that can occur with certain medical conditions or surgical procedures1. One of these conditions is septic shock, which is a life-threatening complication of sepsis, a systemic inflammatory response to infection. Septic shock is characterized by persistent hypotension despite adequate fluid resuscitation, along with signs of organ dysfunction and tissue hypoperfusion. Levophed is used as a first-line vasopressor agent in septic shock to restore adequate perfusion pressure and tissue oxygenation.

Acute respiratory failure, multiple sclerosis, and acute kidney failure are not indications for Levophed treatment. Acute respiratory failure is a condition in which the lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from the blood. It can be caused by various lung diseases, injuries, or infections. The treatment of acute respiratory failure depends on the underlying cause and the severity of the condition, but it may include oxygen therapy, mechanical ventilation, medications to treat infections or inflammation, or other supportive measures. Multiple sclerosis is a chronic autoimmune disease that affects the central nervous system, causing inflammation, demyelination, and axonal damage. The symptoms of multiple sclerosis vary depending on the location and extent of the nerve damage, but they may include vision problems, numbness, weakness, fatigue, cognitive impairment, or pain. The treatment of multiple sclerosis aims to reduce the frequency and severity of relapses, slow the progression of disability, and manage the symptoms. It may include immunomodulatory drugs, corticosteroids, symptomatic medications, physical therapy, or other interventions. Acute kidney failure is a condition in which the kidneys suddenly lose their ability to filter waste products and fluids from the blood. It can be caused by various factors that impair the blood flow to the kidneys, damage the kidney tissue, or block the urine output. The symptoms of acute kidney failure may include decreased urine output, fluid retention, nausea, confusion, or shortness of breath. The treatment of acute kidney failure depends on the underlying cause and the severity of the condition, but it may include fluid management, electrolyte replacement, dialysis, medications to treat infections or inflammation, or other supportive measures.

References:

• CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
• Levophed Uses, Side Effects & Warnings - Drugs.com
• Levophed (Norepinephrine Bitartrate): Uses, Dosage … - RxList
• Levarterenol, Levophed (norepinephrine) dosing … - Medscape
• [Septic Shock: Practice Essentials … - Medscape Reference]
• [Surviving Sepsis Campaign: International Guidelines for … - PubMed]
• [Acute respiratory failure: MedlinePlus Medical Encyclopedia]
• [Multiple sclerosis - Symptoms and causes - Mayo Clinic]
• [Acute kidney failure - Symptoms and causes - Mayo Clinic]

A query should include relevant clinical indicators from the health record that support the need for clarification and the query options. Clinical indicators are objective and measurable signs, symptoms, laboratory results, diagnostic test results, medications, treatments, and other documented findings that are related to a specific diagnosis or condition. Information from previous encounters, the impact on quality, and the impact of reimbursement are not appropriate to include in a query, as they may introduce bias, lead the provider, or imply a desired response.

Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include educating physicians on the importance and impact of clinical documentation on coding, reimbursement, quality measures, compliance, and patient care. The physician advisor/champion can act as a liaison between the CDIPs and the medical staff, provide feedback and guidance on query development and resolution, and facilitate peer-to-peer education sessions on documentation best practices and standards6 References: 1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf  6: https://my.ahima.org/store/product?id=67077

According to the AHIMA best practice for written queries, queries should be limited to non-leading questions that do not imply a specific answer or diagnosis, but rather ask for the provider’s opinion based on their clinical judgment and the evidence in the health record. Non-leading questions help to ensure that the query is compliant, objective, and respectful of the provider’s authority and autonomy. Leading questions, on the other hand, may introduce bias, influence the provider’s response, or compromise the integrity of the documentation and coding. For example, a non-leading query for a patient with chest pain would be: “What is the etiology of the chest pain?” A leading query would be: “Is the chest pain due to acute myocardial infarction?”

References:

• CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)
• Guidelines for Achieving a Compliant Query Practice—2022 Update1

A CDI steering committee is a group of interdisciplinary leaders who oversee and guide the CDI program’s objectives, outcomes, and metrics. The committee should include representatives from finance, clinical, coding, quality, and other areas that are impacted by CDI. The committee should meet regularly to review the CDI program’s performance, identify opportunities for improvement, and provide support and education to the CDI staff and providers. A CDI steering committee can help reinvigorate a stagnant CDI program by ensuring that it aligns with the organization’s vision and mission, addresses the current challenges and needs, and fosters collaboration and communication among stakeholders. The other options are not necessarily effective ways to reinvigorate a CDI program. Expanding the CDI program to larger areas in outpatient clinics may not be feasible or appropriate without a clear strategy and plan. Prioritizing to focus on efforts with the largest return on investment may not reflect the true value and quality of the CDI program. Identifying key metrics to develop program measures for coders may not capture the full scope and impact of the CDI program.

If the provider’s response to the query is different than what was expected by the CDIP, the CDIP should implement the department’s escalation process to ensure the validity and accuracy of the documentation and the coded data. The escalation process is a standardized procedure that involves a manager, committee, or other supervisory position to review and assess the query and the response, and to determine the appropriate next steps. The escalation process may include contacting the provider for clarification, education, or feedback; consulting with a physician advisor/champion or a coding auditor; or reporting the issue to a higher authority or regulatory body. The escalation process should be documented and communicated clearly and respectfully to all parties involved.

A. Record the query response as disagreed. This is not a sufficient action to take if the provider’s response to the query is different than what was expected by the CDIP. Recording the query response as disagreed may indicate a lack of agreement or consensus between the CDIP and the provider, but it does not address the underlying issue of documentation validity or accuracy. It may also create a negative impression or relationship between the CDIP and the provider.

B. Have a different CDI query the provider. This is not an appropriate action to take if the provider’s response to the query is different than what was expected by the CDIP. Having a different CDI query the provider may create confusion, inconsistency, or redundancy in the query process. It may also undermine the credibility or authority of the original CDI who queried the provider.

C. Revise the query and send it back to the provider. This is not a recommended action to take if the provider’s response to the query is different than what was expected by the CDIP. Revising the query and sending it back to the provider may imply that the CDI is dissatisfied or disagreeing with the provider’s response, which may be perceived as disrespectful or confrontational. It may also suggest that the CDI is trying to influence or coerce the provider to change their response, which may compromise the integrity and compliance of the query process.

References:

• CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
• Guidelines for Achieving a Compliant Query Practice—2022 Update | ACDIS
• Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
• The Provider Query Toolkit: A Guide to Compliant Practices

A hospital-acquired condition (HAC) is an undesirable situation or condition that affects a patient and that arose during a stay in a hospital or medical facility. CMS has identified 14 categories of HACs for which it will not pay the higher DRG rate if the condition was not present on admission (POA). One of these categories is stage III and IV pressure ulcers. A pressure ulcer is damage to the skin and underlying tissue caused by prolonged pressure on the skin. Stage III pressure ulcers involve full-thickness skin loss with damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents as a deep crater with or without undermining of adjacent tissue.

A. Iatrogenic pneumothorax with lung biopsy is not a HAC, because it is not included in the CMS HAC list. Iatrogenic pneumothorax is a HAC only when it occurs with venous catheterization.

B. Iatrogenic pneumothorax with venous catheterization is a HAC, but it may be present on admission if the venous catheterization was performed before the admission to the hospital.

C. Pressure ulcer stage II is not a HAC, because only stage III and IV pressure ulcers are included in the CMS HAC list. Stage II pressure ulcers involve partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

References:

• CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
• Hospital Acquired Conditions | CMS
• ICD-10 HAC List | CMS
• Bedsores (pressure ulcers) - Symptoms and causes - Mayo Clinic

APR-DRGs are a patient classification system that assigns each inpatient stay to one of more than 300 base APR-DRGs, and then further stratifies each base APR-DRG into four levels of severity of illness (SOI) and risk of mortality (ROM), based on the number, nature, and interaction of complications and comorbidities (CCs) and major CCs (MCCs). SOI reflects the extent of physiologic decompensation or organ system loss of function, while ROM reflects the likelihood of dying. Both SOI and ROM are used to adjust payment rates, quality indicators, and performance measures for hospitals and other healthcare providers.

The CDI manager can gain more information about the potential opportunities for improvement by auditing focused APR-DRGs that have a high impact on SOI/ROM levels, such as those that have a large variation in relative weights across the four severity levels, or those that have a high frequency or volume of cases. The audit can help identify the documentation gaps, inconsistencies, or inaccuracies that may affect the assignment of SOI/ROM levels, such as missing, vague, or conflicting diagnoses, procedures, or clinical indicators. The audit can also help evaluate the CDI team’s performance in terms of query rate, response rate, agreement rate, and accuracy rate. Based on the audit findings, the CDI manager can develop an education plan for both the CDI team and the physicians to address the specific documentation improvement areas and provide feedback and guidance on best practices.

A. Audit cases for missed diagnosis by the CDI practitioner to target in the education plan. This is not the best way to gain more information about the situation, because it may not capture all the factors that affect SOI/ROM levels, such as procedures, clinical indicators, or interactions among diagnoses. It may also focus only on the CDI practitioner’s performance, without considering the physician’s role in documentation quality and completeness.

B. Audit focused cases by physicians that have a higher SOI/ROM for education plan. This is not a valid way to gain more information about the situation, because it may not identify the documentation improvement opportunities for cases that have a lower SOI/ROM than expected, based on their clinical complexity and acuity. It may also create a perception of bias or favoritism among physicians, if only some are selected for audit and education.

C. Audit cases that have high SOI/ROM assigned by coders for education and follow-up. This is not a reliable way to gain more information about the situation, because it may not reflect the true SOI/ROM levels of the cases, if there are errors or discrepancies in coding or grouping. It may also overlook the documentation improvement opportunities for cases that have low SOI/ROM assigned by coders, despite having high clinical complexity and acuity.

References:

• CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
• 3M™ All Patient Refined Diagnosis Related Groups (APR DRGs) | 3M United States
• Q&A: Understanding SOI and ROM in the APR-DRG system | ACDIS
• Use SOI/ROM scores to enhance CDI program effectiveness | ACDIS

A physician advisor/champion is a physician leader who supports and advocates for the CDI program and its objectives. A physician advisor/champion can help overcome the objections of other physicians by providing education, feedback, guidance, and mentorship on documentation best practices and their impact on revenue, quality, and patient care. A physician advisor/champion can also act as a liaison between the CDI firm and the medical staff, resolve conflicts or discrepancies in documentation, and foster a culture of collaboration and improvement. Physicians are more likely to trust and engage with their peers who understand their clinical perspective and challenges, rather than an external CDI firm that may be perceived as intrusive or disruptive.

A. Create a vision statement that outlines the project objectives. This is not sufficient to collaborate with physicians and overcome their objections. A vision statement is a general statement that describes the desired outcome of the project, but it does not address the specific concerns or questions that physicians may have about the CDI firm’s role, methods, or benefits.

B. Communicate the benefits of the CDI firm about the project. This is not enough to collaborate with physicians and overcome their objections. Communicating the benefits of the CDI firm may be informative, but it may not be persuasive or credible if it comes from the CDI firm itself, without any endorsement or support from a physician leader within the organization.

C. Hire a consultant to communicate the benefits to the physicians. This is not a good way to collaborate with physicians and overcome their objections. Hiring a consultant may add another layer of complexity and cost to the project, and it may not improve the trust or relationship between the CDI firm and the physicians. A consultant may also lack the clinical expertise or authority to influence the physicians’ behavior or attitude.

References:

• CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
• Q&A: Defining roles for physician advisor/champion | ACDIS
• Q&A: The Role of the Physician Advisor in CDI | ACDIS
• The Role of a Physician Advisor - UASI Solutions
• PA/NP in Physician Champion / Advisor Role — ACDIS Forums

According to the AHIMA CDIP Exam Preparation Guide, one of the CDI metrics and statistics that CDI managers should track and interpret is the severity level measured against average length of stay (ALOS)1. This indicator reflects the complexity and acuity of the patient population and the quality of care provided by the hospital2. A low-severity level with a high ALOS may indicate under-documentation or under-coding of the patient’s condition, which may affect the hospital’s reimbursement, risk adjustment, and quality scores3. Therefore, the CDI manager should keep in mind that this indicator is a key factor of measurement for quality reports when discussing this observation with physicians, and educate them on the importance of documenting and coding accurately and completely to reflect the patient’s true severity of illness. The other options are not correct because they do not address the issue of severity level measured against ALOS, or they are not relevant to the CDI manager’s role or responsibility. References:

• CDIP Exam Preparation Guide - AHIMA
• Demystifying and communicating case-mix index - ACDIS
• Severity of Illness: What Is It? Why Is It Important? | HCPro

According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023, the principal diagnosis is defined as "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"2. In this case, the patient was admitted with shortness of breath, productive yellow sputum, and a temperature of 101.2, which are signs and symptoms of pneumonia. The CXR confirmed the diagnosis of LLL pneumonia, which is a serious condition that requires inpatient care. Therefore, LLL pneumonia is the principal diagnosis.

The secondary diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay"2. In this case, the patient had bilateral pleural effusion and kidney failure at the time of admission, which are coexisting conditions that affect the treatment received and/or the length of stay. The renal consult documented AKI with ATN, which is a more specific diagnosis than kidney failure and reflects the severity and etiology of the condition. Therefore, AKI with ATN and bilateral pleural effusion are secondary diagnoses.

References:

• CDI Week 2020 Q&A: CDI and key performance indicators1
• ICD-10-CM Official Guidelines for Coding and Reporting FY 20232

According to AHIMA, best practice for fixing a mistake in a patient health record is that errors are corrected by the clinician who authored the documentation1. The clinician who made the error should identify and correct the inaccurate information, and document the date, time, and reason for the correction1. The correction should also be made in a way that preserves the original content and does not obscure or delete it1. The other options are not correct according to AHIMA. Any physician caring for the patient cannot correct inaccurate record notes, as this may compromise the accountability and integrity of the documentation2. Amendments to record content do not need to be co-signed by the attending physician, unless required by organizational policy or state law3. Coders cannot rely on the laboratory results to confirm the patient’s diagnosis, as they should code based on the physician’s documentation and not on test results alone. References:

• Making Corrections in the Electronic Health Record - AHIMA
• Auditing Copy and Paste - AHIMA
• Amendments, Corrections, and Deletions in Transcribed Reports Toolkit - AHIMA
• [Coding from Test Results | Journal Of AHIMA]

According to the AHIMA/ACDIS Query Practice Brief, one of the fundamental elements that must be in place for a successful DRG discrepancy resolution is a collaborative and respectful interaction between the coder and the CDIP1. The coder and the CDIP should communicate effectively and timely to identify and resolve any DRG mismatches, using evidence-based guidelines, coding conventions, and query standards1. The coder and the CDIP should also share their knowledge and expertise with each other, and seek clarification from the provider or the physician advisor/champion when necessary1. The other options are not considered fundamental elements for DRG discrepancy resolution, although they may be helpful or supportive in some situations. References:

• Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

The coding reference that should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment classification (APC) reimbursement is the AMA CPT Assistant. The CPT Assistant is the official source of guidance from the American Medical Association (AMA) on the proper use and interpretation of the Current Procedural Terminology (CPT) codes, which are used to report outpatient and professional services. The CPT Assistant provides clinical scenarios, frequently asked questions, coding tips, and updates on CPT coding changes. The CPT codes are used to determine the APC reimbursement for outpatient services under the Medicare Outpatient Prospective Payment System (OPPS). (CDIP Exam Preparation Guide)

References:

• CDIP Exam Content Outline1
• CDIP Exam Preparation Guide2
• AMA CPT Assistant3
• Medicare Claims Processing Manual Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS)

According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement2. In this case, the CDIP queried the physician to clarify the current acuity of the diagnosis of chronic systolic heart failure, based on clinical indicators suggestive of an exacerbation of systolic heart failure. The subsequent documentation in the health record that suggests the provider did not understand the query is A. The patient has chronic systolic heart failure. This documentation does not address the query or provide any additional information about the patient’s condition. It simply repeats the same diagnosis that was already documented in the progress note. This documentation does not reflect the patient’s true severity of illness, risk of mortality, or reimbursement3. The other options are not correct because they do provide some information about the current acuity of the diagnosis of chronic systolic heart failure, such as acute on chronic, exacerbation, or decompensation. These terms indicate a higher level of severity and complexity than chronic alone. References:

• CDIP Exam Preparation Guide - AHIMA
• Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
• Severity of Illness: What Is It? Why Is It Important? | HCPro
• [Q&A: Acute on chronic versus decompensated heart failure | ACDIS]

Combination codes are used to classify two diagnoses, a diagnosis with a manifestation, or a diagnosis with an associated complication. A complication is a condition that arises during the hospital stay that prolongs the length of stay by at least one day in approximately 75 percent of cases1. Complications may affect payment and severity of illness and risk of mortality classifications. Examples of combination codes that include a diagnosis with an associated complication are:

• I50.23 Acute on chronic systolic (congestive) heart failure
• K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding
• O34.211 Maternal care for incompetent cervix with cerclage, first trimester

A diagnosis that is an integral part of a disease process is not a valid option for combination codes, because it does not represent a separate or additional condition that needs to be coded. For example, chest pain is an integral part of acute myocardial infarction and does not require a separate code.

A diagnosis with an associated procedure is not a valid option for combination codes, because procedures are coded separately from diagnoses using ICD-10-PCS codes. For example, appendicitis with appendectomy is not a combination code, but rather two codes: one for the diagnosis (K35.80 Acute appendicitis without perforation or gangrene) and one for the procedure (0DTJ4ZZ Resection of appendix, percutaneous endoscopic approach).

A diagnosis with a sequelae or late effect is not a valid option for combination codes, because sequelae or late effects are coded separately from the original condition using the appropriate code from category B90-B94 Sequelae of infectious and parasitic diseases or category I69 Sequelae of cerebrovascular disease, followed by the code for the specific condition2. For example, hemiplegia following cerebral infarction is not a combination code, but rather two codes: one for the sequelae (I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side) and one for the original condition (I63.9 Cerebral infarction, unspecified).

References:

• CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
• ICD-10-CM Official Guidelines for Coding and Reporting FY 2022
• Identifying ICD-10 Combination Codes - Outsource Strategies International

AHIMA suggests that an organization should consider a physician response rate of 80% and an agreement rate of 80% as benchmarks for CDI program performance. These rates indicate the level of physician engagement and documentation accuracy in relation to CDI queries.

References: AHIMA. “Guidelines for Achieving a Compliant Query Practice (2019 Update).” Journal of AHIMA 90, no. 2 (February 2019): 20-29.

The proper sequencing of the principal and secondary diagnoses in this case is as follows:

• Principal diagnosis: Acute appendicitis. This is the condition, after study, that occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. The patient was admitted for laparoscopic surgery, which is a definitive treatment for acute appendicitis. The physician documented “possible acute appendicitis or probable Meckel diverticulitis” as the cause of the right lower quadrant abdominal pain. According to the AHA’s Coding Clinic, Fourth Quarter 2016, pp. 147-148, when a physician documents two diagnoses connected by “or”, coders should query the physician for clarification if possible. However, if a query is not possible or not answered, coders should assign codes for both conditions, unless one of them has been ruled out or confirmed by further testing or treatment. In this case, there is no indication that either acute appendicitis or Meckel diverticulitis has been ruled out or confirmed by further testing or treatment. Therefore, both conditions should be coded and reported. However, only one of them can be the principal diagnosis. Since acute appendicitis is more commonly associated with laparoscopic surgery than Meckel diverticulitis, and since it has a higher relative weight than Meckel diverticulitis under the MS-DRG system, it is reasonable to select acute appendicitis as the principal diagnosis 23.
• Secondary diagnosis: Right lower quadrant abdominal pain. This is a sign or symptom that is associated with the principal diagnosis and requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. The patient presented with right lower quadrant abdominal pain as a manifestation of acute appendicitis or Meckel diverticulitis. The pain required clinical evaluation by abdominal ultrasound and therapeutic treatment by laparoscopic surgery. Therefore, it should be coded and reported as a secondary diagnosis 4.
• Secondary diagnosis: Type I diabetes mellitus. This is a chronic condition that affects the patient’s care in terms of requiring diagnostic or therapeutic services or affecting patient outcomes or resource utilization. The patient has a history of type I diabetes mellitus and received an injection of neutral protamine Hagedorn insulin to normalize the blood sugar level prior to surgery. Therefore, it should be coded and reported as a secondary diagnosis 4.

References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section II.A 3: AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Fourth Quarter 2016 4: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section III.C : AHIMA CDIP Exam Prep, Fourth Edition https://my.ahima.org/store/product?id=67077

When queries are part of the health record, which is recommended by AHIMA and ACDIS, physicians are responsible for responding to queries in a timely manner and ensuring that their documentation is complete and accurate. If a provider receives too many deficiencies due to incomplete records for failure to respond to queries, their admitting privilege could be suspended by the medical staff committee as a disciplinary action.

References: AHIMA/ACDIS. “Guidelines for Achieving a Compliant Query Practice (2019 Update).” Journal of AHIMA 90, no. 2 (February 2019): 20-29.

According to the Documentation Integrity Practitioner (CDIP®) study guide, the physician with the highest number of unanswered queries would benefit from additional education. In this case, Dr. D has the highest number of unanswered queries with 9. Unanswered queries may indicate a lack of understanding, engagement, or compliance with the query process, which may affect the quality and accuracy of clinical documentation and coding1. Therefore, Dr. D would best benefit from additional education for unanswered queries, such as the importance of timely and appropriate query responses, the impact of queries on severity of illness, risk of mortality, and reimbursement, and the best practices for a compliant query practice2. References:

• Q&A: What to do with unanswered queries | ACDIS
• Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

A leading query is one that suggests a specific diagnosis, condition, or treatment to the provider, or implies that a certain response is desired or expected. A leading query can compromise the integrity and accuracy of the documentation and the coded data, and may also raise compliance and ethical issues. A query should be non-leading, meaning that it presents the facts from the health record without bias or influence, and allows the provider to use their clinical judgment to determine the appropriate response.

The query in the question is leading because it implies that the patient’s CHF is systolic by asking a yes/no question that only offers one option. A non-leading query would ask an open-ended question that offers multiple options, such as “What type of CHF does this patient have?” or “Please specify the type of CHF: systolic, diastolic, or combined.”

References:

• CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
• Guidelines for Achieving a Compliant Query Practice—2022 Update | ACDIS
• Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
• The Provider Query Toolkit: A Guide to Compliant Practices

A post-discharge query is needed to obtain a more specific principal diagnosis with the highest level of severity of illness (SOI) and risk of mortality (ROM) for this patient. The discharge diagnosis of health care associated pneumonia (HCAP) is not specific enough to capture the etiology, site, and severity of the pneumonia. Based on the clinical indicators in the case scenario, such as the history of aspiration, the chest x-ray findings, the elevated white blood count, the fever, and the antibiotic treatment, a more specific diagnosis of aspiration pneumonia would be appropriate. Aspiration pneumonia is a type of pneumonia that occurs when foreign material, such as food or vomit, is inhaled into the lungs, causing inflammation and infection. Aspiration pneumonia has a higher SOI and ROM than HCAP because it is associated with more complications and poorer outcomes 1.

Additionally, the discharge diagnosis of altered mental status is vague and does not reflect the underlying cause or severity of the condition. Based on the clinical indicators in the case scenario, such as the fever, the low sodium level, the moaning and disorientation, and the venous blood gas results, a more specific diagnosis of septic encephalopathy would be appropriate. Septic encephalopathy is a type of delirium that occurs when sepsis affects the brain function, causing confusion, agitation, or reduced consciousness. Septic encephalopathy has a higher SOI and ROM than altered mental status because it indicates a systemic inflammatory response and multi-organ dysfunction 2.

Furthermore, the discharge diagnosis of respiratory distress is also vague and does not reflect the underlying cause or severity of the condition. Based on the clinical indicators in the case scenario, such as the shortness of breath, the accessory muscle use, the respiratory rate, and the bilevel positive airway pressure treatment, a more specific diagnosis of acute hypoxemic respiratory failure would be appropriate. Acute hypoxemic respiratory failure is a type of respiratory failure that occurs when there is insufficient oxygen exchange in the lungs, causing low oxygen levels in the blood. Acute hypoxemic respiratory failure has a higher SOI and ROM than respiratory distress because it indicates a life-threatening condition that requires mechanical ventilation or oxygen therapy 3.

Finally, based on the clinical indicators in the case scenario, such as the fever, the elevated white blood count, and the antibiotic treatment, a diagnosis of sepsis should also be included in the query. Sepsis is a serious complication of infection that occurs when the body’s immune system overreacts to an infection and causes widespread inflammation and organ damage. Sepsis has a high SOI and ROM because it can lead to septic shock or death if not treated promptly 4.

Therefore, a post-discharge query should ask the provider to confirm or rule out aspiration pneumonia, hyponatremia (low sodium level), septic encephalopathy, and sepsis with acute hypoxemic respiratory failure as possible diagnoses for this patient. These diagnoses would result in a more specific principal diagnosis with the highest level of SOI and ROM for this patient.

References:

• CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)
• Aspiration Pneumonia - an overview | ScienceDirect Topics1
• Septic Encephalopathy - an overview | ScienceDirect Topics2
• Acute Hypoxemic Respiratory Failure - an overview | ScienceDirect Topics3
• Sepsis - Symptoms and causes - Mayo Clinic4

According to AHIMA, clinical documentation is at the core of every patient encounter and it must be meaningful to accurately reflect the patient’s disease burden and scope of services provided. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible1. Reliability is one of the criteria for clinical documentation that means the content of the record is trustworthy, safe, and yielding the same result when repeated1. Reliability ensures that the documentation is consistent with the clinical evidence and reasoning, and that it can be verified by other sources or methods. Reliability also implies that the documentation is free from errors, omissions, contradictions, or ambiguities that could compromise its validity or usefulness1.

References:

• Clinical Documentation Integrity Education & Training | AHIMA1

The member of the clinical documentation integrity (CDI) team who can help provide peer-to-peer level of education on the importance of accurate documentation and query responses is the physician advisor/champion. The physician advisor/champion is a physician who supports and advocates for the CDI program and its goals, and who can communicate effectively with other physicians about the clinical and financial implications of documentation quality and accuracy. The physician advisor/champion can also serve as a liaison between the CDI team and the medical staff, and help to resolve any issues or conflicts that may arise from the query process. The physician advisor/champion can also provide feedback and guidance to the CDI team on clinical matters and documentation standards. (CDIP Exam Preparation Guide)

References:

• CDIP Exam Content Outline1
• CDIP Exam Preparation Guide2

A noncompliant query includes querying the provider regarding gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators because it may lead to over-specification of a diagnosis that is not supported by the health record. A compliant query should be based on the clinical evidence and documentation in the record, and should not suggest or imply a diagnosis that is not clinically relevant or plausible. A query should also not be driven by reimbursement or coding factors, but by the need to improve the quality and accuracy of documentation. (CDIP Exam Preparation Guide)

References:

• CDIP Exam Content Outline1
• CDIP Exam Preparation Guide2
• Guidelines for Achieving a Compliant Query Practice (2019 Update)3