Get CDIP Dumps : Verified Certified Documentation Integrity Practitioner

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]

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/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

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 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