第 32 号 Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?

NO.33 Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?

NO.34 Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital’s clinical documentation integrity (CDI) program?

第 35 号 Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner’s role within the organization?

第 36 号 Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?

NO.37 The facility has received a clinical validation denial for sepsis. The denial states sepsis is not a clinically valid diagnosis because it does not meet Sepsis-3 criteria. The facility has a policy stating it uses Sepsis-2 criteria.
What is the BEST next step?

第 38 号 Hospital policy states that physician responses to queries should be no longer than timely payer filing requirements. A physician responds to a query after the final bill has been submitted. How should administration respond in this situation?

第 39 号 What is the term used when a patient is entered in the Master Patient Index (MPI) multiple times, in different ways, resulting in multiple medical record numbers?

NO.40 What type of laboratory test is a creatinine test?

第 41 号 Which of the following should be examined when developing documentation integrity projects?

第 42 号 When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to

第 43 号 Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

NO.44 An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?

第 45 号 Which of the following diagnosis is MOST likely to trigger a second level review?

第 46 号 A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

NO.47 The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is

第 48 号 A clinical documentation integrity practitioner (CDIP) has been successful in getting physicians to respond to queries. However, when the CDIP poses a query to a specific doctor, there is no response at all. The CDIP has tried face-to-face conversations, calling, emails, texts, but still gets no response. What is the next step the CDIP should take?

NO.49 A resident returns to the long-term care facility following hospital care for pneumonia. The physician’s orders and progress note state “Continue IV antibiotics for pneumonia – 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia”. Is it appropriate to code the pneumonia in this scenario?

NO.50 A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician’s documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit. Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD.
Discharge diagnoses:
1. Pneumonia
2. COPD
3. Current smoker
What is the correct diagnostic related group assignment?

第 51 号 Educating physicians on severity of illness and risk of mortality is best accomplished by utilizing

第 52 号 Which physician would best benefit from additional education for unanswered queries?

第 53 号 A modifier may be used in CPT and/or HCPCS codes to indicate

第 54 号 A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient’s history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient’s diagnosis. Which response provides the highest level of specificity?

第 55 号 What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

NO.56 A query should include