What is Missing
Patient has chronic heart failure with a recent echo showing an EF of 55%.
What is the type of heart failure, diastolic.
Per policy, queries are expected to be answered within _____ hours.
What is 72.
This is a primary reason for the demand for high-quality clinical documentation.
What is accurate coding.
After further testing, this statement indicates that a potential diagnosis is not present.
What is ruled out.
A goal of every CDI program is to obtain high-quality clinical documentation prior to _________. (Hint: The reason for concurrent reviews.)
What is the patient being discharged from the hospital.
True or False: Medical codes must match the recorded clinical documentation.
True
Rationale: Clinical documentation is the basis of all medical coding processes. Medical codes must be supported by documentation from the patient record.
Patient presented with an acute GI bleed and anemia. His hemoglobin was 6.5 and he received 1 unit of PRBC and a GI consult.
What is the acuity and specificity of the anemia, acute blood loss anemia.
This is the hopeful result with continued querying and follow-up training.
What is the reduction in query rate.
This allows the diagnostic, treatment, and response of information of the patient to be aggregated into a uniform data set.
What is coding.
Documentation that allows an uncertain diagnosis to still be coded if included in the discharge summary.
What is any of the following:
Probable, suspected, possible, and likely.
This is key to the success and sustainability of the CDI program.
What is physician support.
True or False: The physician advisor's role is to discipline physicians who do not improve documentation.
False.
Part of the physician advisor's role is to support CDI with education and peer-to-peer review of documentation.
Patient presents with advanced dementia, Parkinson's disease, multiple skin tears, and a stage 4 pressure ulcer. Surgery completed an excision debridement on day 2 and the patient was started on antibiotics.
What is the location of the pressure ulcer.
This person is responsible for answering the query after the patient is discharged.
Who is the provider that completed the discharge summary.
This form of documentation is the essence of the health record on which the coder most heavily relies on.
What are progress notes.
This statement is used to indicate when a confirmed diagnosis was treated and is no longer present.
What is resolved.
The health record review process and this other aspect allow for the highest level of quality in clinical documentation.
What are physician queries.
True or False: Queries would only be initiated when the clarification would affect reimbursement.
False
Rationale: Queries can be initiated to clarify multiple aspects of the health record, including:
a. conflicting, imprecise, illegible, ambiguous, or inconsistent information
b. description of clinical indicators that are not associated with a documented underlying diagnosis.
c. it is unclear if the health issue was POA or developed as an HAC.
Patient has a history of HFpEF, HTN, COPD on continous home O2 at 2lpm, and CKD stage III.
What is chronic hypoxic respiratory failure.
The most frequently sent queries were for these two diagnoses.
Pressure ulcers and malnutrition.
One of the following provider's documentation cannot be used to support coding.
A. Admitting Hospitalist
B. Pathologist
C. Cardiology Consult Physician
D. Surgery Nurse Practitioner
What is B. Pathologist.
CP and PE are examples of this.
What are Doppelganger medical abbreviations.
CP could be chest pain or cerebral palsy.
PE could be pulmonary embolism or pleural effusion.
This person is the physician advisor for both CDI and Utilization Review for CVPH.
Who is Dr. Hoffman.
True or False: Provider queries are a permanent part of the medical record.
True. All answered queries will automatically become a progress note in the chart.
Patient admitted with complaints of severe back and abdominal pain with nausea and vomiting. She was seen in the ED multiple times over the past 6 months, and records show a weight loss of 20 pounds. She states she has had difficulty eating. Patient does appear to be jaundiced, with thinning skin and significant muscle/fat loss. It is determined that patient has severe weight loss, inability to eat, vomiting. A query might be sent for this diagnosis.
What is severe malnutrition.
The reasons a provider might receive a query include: to provide more specificity, clarify acuity, to provide additional support for a diagnosis, and this.
What is identify a missing diagnosis.
Accurate and complete documentation can help reduce the chances of this post biling event.
What is a denial.
This statement is used when a patient has an exacerbation of a current condition such as respiratory failure.
What is acute on chronic.
This type of physician is often top priority for CDI training and account for, on average, 60 percent of the hospital admissions.
Who are the Hospitalists.
True or False: The purpose of CDI is to only increase reimbursement.
False
Rationale: The purpose of CDI is to improve documentation, which supports many functions including reimbursement, quality measures, patient care through communication, reduce legal risk, and more.