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.
72 Hours
This is the reason for the demand for high-quality documentation.
Having a complete and accurate record that reflects the full patient story and also facilitates accurate coding.
After further testing, this statement indicates that a potential diagnosis is not present.
What is ruled out.
This is the chief concept of CDI.
What is the ability to understand the provider's intent.
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 provider is ultimately responsible for the documentation of all applicable diagnoses within the current encounter.
Attending provider.
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.
These are the top two diagnoses most often queried for.
Malnutrition (and acuity) and Pressure Ulcers (location and POA)
This 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 supports CDI on a physician level.
What is a physician advisor.
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 presents to the ED with shortness of breath, with increased work of breathing, using accessory muscles, speaking in one-word responses. O2 saturation found to be 83% on room air. Patient placed on NRB 40L. Acute hypoxia documented in the H&P.
Acute hypoxic respiratory failure
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 billing event.
What is a denial.
This statement is used when a patient has a sudden worsening of a chronic condition such as systolic heart failure.
What is acute on chronic.
This is the CDI's role in coding.
What is understanding and staying current in coding guidelines and clinics.
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.