Clue Hunt The Detectives' Trail
What’s the first thing a CDI detective looks for when cracking a clinical case? (Hint: It’s in the H&P)
Chief complaint and history of present illness (HPI) – the foundation for identifying the principal diagnosis
What does "MEAT" stand for in documentation?
Monitor, Evaluate, Assess, Treat
What coding system is used for inpatient diagnoses?
ICD-10-CM
What is the purpose of a physician query?
To clarify documentation for accurate coding
A patient presents with confusion and elevated ammonia. What diagnosis might be considered?
Hepatic encephalopathy
You find a trail of abnormal labs and a fever. What condition might be hiding in plain sight?
Sepsis – look for systemic signs of infection and organ dysfunction
Why is it important to document the type of heart failure?
Impacts coding specificity and severity (e.g., systolic vs. diastolic, acute vs. chronic)
What is the principal diagnosis?
The condition chiefly responsible for admission
What makes a query compliant?
Non-leading, based on clinical indicators, includes multiple options
A patient has low BP, high lactate, and fever. What condition could this indicate?
Septic shock
A patient’s chart has conflicting documentation. What’s your next move as a CDI sleuth?
Issue a compliant query to clarify the inconsistency
What term should be avoided when documenting altered mental status?
"Confusion" – too vague, consider encephalopathy or delirium
What does MCC stand for?
Major Complication or Comorbidity
What should be avoided in a leading query?
Suggesting a diagnosis without clinical support
A patient has a creatinine of 3.0 and decreased urine output. What diagnosis should be explored?
Acute kidney injury
You spot a vague term like “altered mental status.” What diagnosis might be lurking beneath?
Encephalopathy – consider hepatic, metabolic, or toxic causes
What documentation supports encephalopathy?
Altered mental status, abnormal EEG, elevated ammonia
What coding impact does a query clarification have?
Can lead to more accurate coding and DRG assignment
What is the role of the CDI specialist in query writing?
Identify gaps, write compliant queries, educate providers
A patient has bilateral infiltrates on chest X-ray and low oxygen saturation. What diagnosis is likely?
Acute respiratory failure due to pneumonia
The case has multiple clues: low BP, high lactate, and infection. What’s the likely culprit diagnosis?
Septic shock – a severe manifestation of sepsis with circulatory and metabolic abnormalities
What’s the impact of vague terms like “likely” or “possible” in documentation?
They prevent code assignment; need definitive or supported diagnoses
How does coding affect hospital reimbursement?
Determines DRG, which drives payment under IPPS
Name one regulatory body that oversees query compliance.
AHIMA, ACDIS, CMS
A patient has altered mental status, no prior dementia, and abnormal EEG. Elevate Creatinine, and potassium. What diagnosis could be queried?
Metabolic Encephalopathy