CDI Basics
CDI Stands for this.
What is Clinical Documentation Improvement?
This coding system is used to classify diagnoses in the U.S. healthcare system.
What is ICD-10-CM?
A heart attack is clinically referred to as
What is myocardial infraction?
This U.S. law protects patient information.
What is HIPAA?
True or False: CDI specialist can suggest a diagnoses directly to a physician.
What is False?
These are the three main goals of CDI.
What are improving quality, ensuring compliance and optimizing reimbursement?
The presence of this type of condition (MCC) can significantly impact the DRG assignment.
What is a Major Complication or Comorbidity?
The abbreviation AKI stands for this condition.
What is acute Kidney Injury?
This government agency oversees Medicare and Medicaid documentation Compliance
What is CMS (Centers for Medicare & Medicaid Services)?
The official guidelines states that physician queries must always be this (two words).
What is non-leading?
The first large-scale implementation of CDI programs in the U.S. occurred in this decade.
What is the 2000s?
This DRG grouper version is currently in use for Medicare inpatient hospital reimbursement.
What is MS-DRG (Medicare Severity DRG)?
This clinical term refers to low oxygen in the blood.
What is hypoxemia?
The "Two-Midnight Rule" helps determine this type of patient status.
What is inpatient vs. observation?
AHIMA and ACDIS issued joint practice guidelines for physician queries in this year.
What is 2013?
This official coding guideline requires that a diagnosis be supported by clinical evidence in the documentation, even if the provider states it explicitly.
What is the "clinical validation" requirement?
This type of DRG is impacted by the presence or absence of MCCs or CCs and reflects the relative resource intensity required to treat a patient.
What is a Medicare Severity Diagnosis-Related Group (MS-DRG)?
This term refers to a condition that is present at the time of inpatient admission and is crucial for determining hospital-acquired conditions and quality metrics.
What is Present on Admission (POA)?
According to AHIMA and ACDIS guidelines, this term refers to a communication tool used to clarify documentation in the health record and must never include references to reimbursement or quality metrics.
What is a compliant query?
According to AHIMA and ACDIS guidelines, this essential component must be present in every query to justify the need for clarification and ensure compliance.
What are clinical indicators from the health record?
This documentation element is essential for supporting hierarchical condition categories (HCCs) and risk adjustment models and must be present at least once per calendar year to be valid.
MEAT (Monitored, Evaluated, Assessed, or Treated) criteria-supported diagnosis?
This coding principle states that a diagnosis must be documented by the provider and supported by clinical evidence to be coded, even if it appears in lab results or imaging.
What is the Uniform Hospital Discharge Data Set (UHDDS) guideline?
This term refers to a condition that is not clearly defined in documentation and may require a query to clarify whether it represents a symptom, a diagnosis, or a clinical indicator.
What is a nonspecific or ambiguous clinical term?
This federal agency outlines best practices for provider queries, emphasizing that queries must never suggest diagnoses for reimbursement purposes and must include only clinically supported options.
What is the Office of Inspector General (OIG)?
According to AHIMA and ACDIS, this type of query must include only clinically relevant options supported by documentation, and must also offer an “Other” or “Unable to Determine” option to ensure neutrality.
What is a compliant multiple-choice query?