CDIP Certified Documentation Integrity Practitioner Questions and Answers

The coding reference that should be used to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes 1 and 2 is the ICD-10-CM Official Guidelines for Coding and Reporting. This document provides the conventions and instructions for the proper use of the ICD-10-CM classification system, including the definitions and examples of the Includes Notes and Excludes Notes 1 and 2.  The document is updated annually by the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), and is available online at  2 . The other coding references listed are not specific to ICD-10-CM or do not contain the general rules for the Includes Notes and Excludes Notes 1 and 2.

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  133  3   2 : ICD-10-CM Official Guidelines for Coding and Reporting FY 2021  4

The manager of HIM/Coding should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives because they are responsible for overseeing the coding and billing processes, ensuring compliance with coding guidelines and regulations, and collaborating with the CDI team to resolve coding and documentation discrepancies. The manager of HIM/Coding can also provide feedback on the CDI program’s impact on coding quality, accuracy, productivity, and reimbursement. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

The Agency for Healthcare Research and Quality (AHRQ) provides external benchmarks to examine the effectiveness of a facility’s clinical documentation program by developing and disseminating quality indicators (QIs) that measure various aspects of health care quality, such as patient safety, outcomes, efficiency, and effectiveness. These QIs are based on administrative data and can be used to compare the performance of different health care providers or facilities across the nation. The QIs include inpatient quality indicators (IQIs), patient safety indicators (PSIs), prevention quality indicators (PQIs), and pediatric quality indicators (PQIs).  These QIs can help clinical documentation improvement (CDI) programs identify areas of improvement, monitor trends, and evaluate the impact of CDI interventions on health care quality  2 .

References :  1 : Clinical Documentation Improvement Programs: Quality, Efficiency | Deloitte US Analysis  2   2 : AHRQ Quality Indicators  3

The physician advisor/champion is a key role in the CDI program who serves as a liaison between the CDI staff and the organization’s medical and surgical staff. The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the organization’s medical and surgical staff to promote awareness, understanding, and compliance with CDI initiatives and goals.

References : AHIMA. “CDIP Exam Preparation.” AHIMA Press, Chicago, IL, 2017: 97-98.

The first step that a clinical documentation integrity practitioner (CDIP) should take to determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary is to review the history and physical (H & P) because it is the initial source of information about the patient’s condition at the time of admission. The H & P should include a comprehensive physical examination that covers all body systems, including the skin. If the H & P documents the presence of a stage IV sacral decubitus ulcer, then the POA status is “yes”. If the H & P does not mention the ulcer, then the CDIP should look for other sources of documentation, such as wound care notes, nursing notes, or progress notes, to see if the ulcer was identified or treated during the hospital stay. If there is no clear evidence of when the ulcer developed, then the CDIP should query the attending provider to clarify the POA status. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

Present on Admission Reporting Guidelines 3

A query should be generated when the documentation is conflicting, meaning that there is contradictory or inconsistent information in the medical record that may affect the accuracy of coding, quality reporting, or reimbursement. For example, if the documentation in the progress notes differs from the documentation in the discharge summary, or if different providers document different diagnoses or procedures for the same patient, a query may be needed to resolve the discrepancy and obtain clarification from the source of the documentation. A query should not be generated when the documentation is legible, consistent, or complete, as these are desirable characteristics of documentation that do not require further clarification or verification.

References :

CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)

Accurate Documentation is Essential – Knowing When to Query your Providers 1

Combination codes are used to classify two diagnoses, a diagnosis with a manifestation, or a diagnosis with an associated complication.  A complication is a condition that arises during the hospital stay that prolongs the length of stay by at least one day in approximately 75 percent of cases 1 . Complications may affect payment and severity of illness and risk of mortality classifications. Examples of combination codes that include a diagnosis with an associated complication are:

I50.23 Acute on chronic systolic (congestive) heart failure

K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding

O34.211 Maternal care for incompetent cervix with cerclage, first trimester

A diagnosis that is an integral part of a disease process is not a valid option for combination codes, because it does not represent a separate or additional condition that needs to be coded. For example, chest pain is an integral part of acute myocardial infarction and does not require a separate code.

A diagnosis with an associated procedure is not a valid option for combination codes, because procedures are coded separately from diagnoses using ICD-10-PCS codes. For example, appendicitis with appendectomy is not a combination code, but rather two codes: one for the diagnosis (K35.80 Acute appendicitis without perforation or gangrene) and one for the procedure (0DTJ4ZZ Resection of appendix, percutaneous endoscopic approach).

A diagnosis with a sequelae or late effect is not a valid option for combination codes, because sequelae or late effects are coded separately from the original condition using the appropriate code from category B90-B94 Sequelae of infectious and parasitic diseases or category I69 Sequelae of cerebrovascular disease, followed by the code for the specific condition 2 . For example, hemiplegia following cerebral infarction is not a combination code, but rather two codes: one for the sequelae (I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side) and one for the original condition (I63.9 Cerebral infarction, unspecified).

References :

CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530

ICD-10-CM Official Guidelines for Coding and Reporting FY 2022

Identifying ICD-10 Combination Codes - Outsource Strategies International

A drastic drop in the physician query rate might indicate to the CDI manager that the CDI staff need education on identifying query opportunities. The physician query rate is a metric that measures the percentage of records that have at least one query sent by the CDI staff to clarify or improve the documentation. A high query rate may reflect a high level of documentation quality issues or a high level of CDI staff vigilance and expertise.  A low query rate may reflect a low level of documentation quality issues or a low level of CDI staff awareness and competence  2 . Therefore, a drastic drop in the query rate could suggest that the CDI staff are missing some query opportunities or are not following the query policies and procedures.  The CDI manager should investigate the reasons for the drop and provide education and feedback to the CDI staff on how to identify and address query opportunities effectively and compliantly  3 .

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  133  4   2 : Understanding CDI Metrics - AHIMA  2   3 : The Natural History of CDI Programs: A Metric-Based Model  5

Sharing the mission of the CDI program should be done to ensure a clear sense of what CDI is and the CDI practitioner’s role within the organization. The mission statement defines the purpose, goals, and values of the CDI program, and how it aligns with the organization’s vision and strategy. The mission statement also communicates the benefits and expectations of the CDI program to various stakeholders, such as providers, executives, coders, quality staff, and patients.  The mission statement can help establish the credibility, professionalism, and identity of the CDI practitioners, and guide their daily activities and decisions  2 .

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  133  3   2 : Mission CDI: Guiding goals, values, and principles  1

The entity that has the following regulation is the Centers for Medicare & Medicaid Services (CMS), which is the federal agency that oversees the Medicare and Medicaid programs and sets the Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) for health care organizations that participate in these programs. The regulation that requires a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, is part of the CoPs for Hospitals, which are located in 42 CFR § 482.24. This regulation was revised in 2007 to align with the Joint Commission’s standard and to provide more flexibility and consistency for hospitals and practitioners. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

42 CFR § 482.24 3

The specificity of pseudomonas pneumonia would increase the relative weight of the diagnosis-related group (DRG) for the patient’s admission, which would affect the reimbursement for the hospital. Relative weight is a factor that reflects the average cost and resource use of a DRG compared to the average cost and resource use of all DRGs. The higher the relative weight, the higher the payment for the hospital. Pseudomonas pneumonia is classified as a major complication or comorbidity (MCC) in ICD-10-CM, which means that it significantly increases the severity of illness and risk of mortality of the patient. MCCs increase the relative weight of a DRG by assigning it to a higher-paying subclass within the same base DRG.  For example, according to the CMS FY 2022 Inpatient Prospective Payment System Final Rule 1 , the relative weight for DRG 193 (Simple pneumonia and pleurisy with MCC) is 1.4819, while the relative weight for DRG 195 (Simple pneumonia and pleurisy without MCC) is 0.7579. Therefore, if the patient is admitted due to pneumonia and has pseudomonas pneumonia as an MCC, the hospital would receive a higher payment than if the patient does not have an MCC.

References :

CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)

CMS FY 2022 Inpatient Prospective Payment System Final Rule 1

The first line of escalation for an unanswered query is the CDI Manager because they are responsible for overseeing the CDI program and ensuring compliance with query policies and procedures. The CDI Manager can monitor the query response rates, identify the providers who are not responding, and communicate with them to address any issues or barriers. The CDI Manager can also provide education and feedback to the providers on the importance and benefits of timely query responses. If the CDI Manager is unable to resolve the problem, then they can escalate it to the next level, such as the Medical Director or the CDI Steering Committee. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

Q & A: Establishing an escalation policy for inappropriate queries 3

The name of the medication (aspirin), the date, time and location where it was last administered should be documented in the health record for inpatients with a discharge principal diagnosis of acute myocardial infarction, unless a contraindication to aspirin is documented. This is because aspirin is a core measure for acute myocardial infarction patients, and its administration within 24 hours of arrival is an indicator of quality of care and patient safety.  The date, time and location are important to verify that the medication was given within the specified timeframe and to avoid duplication or omission of doses 4   References :  1 : https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf  4 : https://my.ahima.org/store/product?id=67077

The appropriate action in this case is to query the physician to see if acute renal failure is clinically supported. This is because the patient has signs and symptoms of acute renal failure, such as oliguria, pulmonary edema, and elevated creatinine, but the diagnosis is not documented in the medical record. Acute renal failure is a clinical syndrome characterized by a rapid decline in kidney function and accumulation of metabolic waste products. It can be caused by various factors, such as dehydration, hypovolemia, sepsis, nephrotoxins, or obstruction.  Acute renal failure can be classified according to the RIFLE criteria (Risk, Injury, Failure, Loss, End-stage kidney disease) or the AKIN criteria (Acute Kidney Injury Network), which are based on changes in serum creatinine and urine output  2 3 . A query to the physician is needed to confirm or rule out the diagnosis of acute renal failure, specify the etiology and severity of the condition, and document any associated complications or comorbidities. A query to the physician will also improve the accuracy and completeness of the documentation and coding, and reflect the true clinical picture and resource utilization of the patient.

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  133  4   2 : Acute Kidney Injury: Diagnosis and Management | AAFP  3 : AKIN Classification for Acute Kidney Injury (AKI) - MDCalc

According to the AHIMA-ACDIS Practice Brief, a query escalation policy should describe how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, the department director, or administration with defined actions as to the responsibilities at each level.  The policies should reflect a method of response that can realistically occur for the organization 1 .  In this case, since the attending physician has not responded to the query in an appropriate time frame, the CDIP should escalate the issue to the medical staff leadership, such as the chief medical officer, the department chair, or the physician advisor, who can facilitate communication and education with the attending physician and ensure documentation integrity and compliance 1 .

References :

Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA 1

A query should be generated to ask the physician for the POA indicator of the fall because the documentation is unclear whether the fall was present at the time of inpatient admission or not. The POA indicator is used to identify conditions that are present or not present at the time of admission, and has payment implications for certain hospital-acquired conditions (HACs). According to CMS, a fall resulting in trauma is one of the HACs that will not be paid at a higher rate if it is not present on admission. Therefore, it is important to clarify the POA indicator of the fall to ensure accurate coding and reimbursement. A query should be non-leading, concise, clear, relevant, and consistent with CDI standards and guidelines.

References :

CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)

Coding | CMS 1

Present on Admission Indicators - Novitas Solutions 2

Inconsistent clinically relevant queries may make physicians lose respect for CDI efforts and disengage because they may perceive them as irrelevant, redundant, or contradictory. Clinically relevant queries are those that affect the quality of care, patient safety, severity of illness, risk of mortality, or reimbursement. Inconsistent queries may result from lack of standardization, conflicting guidelines, poor communication, or lack of clinical validation.  To avoid inconsistency, CDI practitioners should follow best practices such as using evidence-based criteria, adhering to query policies and procedures, collaborating with coding and quality staff, and seeking feedback from physicians and physician advisors  2 .

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  136  3   2 : Proactive CDI: Tackling the Problem of Physician Engagement  4

According to the ACDIS Practice Brief, a query escalation policy should describe how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, the department director, or administration with defined actions as to the responsibilities at each level.  The policies should reflect a method of response that can realistically occur for the organization 1 . In this case, since two physicians have significantly lower query response rates than the target, the CDI physician advisor/champion should schedule individual meetings with each low-performing physician to provide feedback, education, and support. A group meeting with all physicians may not be effective or efficient, as it may not address the specific barriers or challenges faced by the low-performing physicians. A meeting with the chair of the gastroenterology department may be helpful, but it may not be sufficient to resolve the issue without direct communication with the low-performing physicians.

References :

CDI Week 2020 Q & A: CDI and key performance indicators 1

Blood incompatibility is considered a hospital-acquired condition if not present on admission, according to the CMS Hospital-Acquired Conditions (HAC) Reduction Program. This program reduces payments to hospitals that have high rates of certain conditions that are acquired during the hospital stay and could have been prevented by following evidence-based guidelines.  Blood incompatibility is one of the 14 HAC categories that are included in the program, and it refers to a patient receiving a blood transfusion with incompatible blood type or Rh factor, which can cause serious adverse reactions such as hemolysis, anemia, renal failure, or death  2 3 .  Blood incompatibility is a preventable condition that can be avoided by proper blood typing and cross-matching before transfusion, and by following strict protocols and procedures for blood handling and administration  4 .

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  133  5   2 : Hospital-Acquired Conditions | CMS  1   3 : Hospital Acquired Conditions (HACs) - New York State Department of Health  3   4 : Transfusion Reactions - Hematology and Oncology - Merck Manuals Professional Edition  6

If the provider’s response to the query is different than what was expected by the CDIP, the CDIP should implement the department’s escalation process to ensure the validity and accuracy of the documentation and the coded data. The escalation process is a standardized procedure that involves a manager, committee, or other supervisory position to review and assess the query and the response, and to determine the appropriate next steps. The escalation process may include contacting the provider for clarification, education, or feedback; consulting with a physician advisor/champion or a coding auditor; or reporting the issue to a higher authority or regulatory body. The escalation process should be documented and communicated clearly and respectfully to all parties involved.

A. Record the query response as disagreed. This is not a sufficient action to take if the provider’s response to the query is different than what was expected by the CDIP. Recording the query response as disagreed may indicate a lack of agreement or consensus between the CDIP and the provider, but it does not address the underlying issue of documentation validity or accuracy. It may also create a negative impression or relationship between the CDIP and the provider.

B. Have a different CDI query the provider. This is not an appropriate action to take if the provider’s response to the query is different than what was expected by the CDIP. Having a different CDI query the provider may create confusion, inconsistency, or redundancy in the query process. It may also undermine the credibility or authority of the original CDI who queried the provider.

C. Revise the query and send it back to the provider. This is not a recommended action to take if the provider’s response to the query is different than what was expected by the CDIP. Revising the query and sending it back to the provider may imply that the CDI is dissatisfied or disagreeing with the provider’s response, which may be perceived as disrespectful or confrontational. It may also suggest that the CDI is trying to influence or coerce the provider to change their response, which may compromise the integrity and compliance of the query process.

References :

CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530

Guidelines for Achieving a Compliant Query Practice—2022 Update | ACDIS

Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

The Provider Query Toolkit: A Guide to Compliant Practices

A yes/no 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 because it may lead to leading or suggesting a diagnosis that is not supported by the provider’s documentation. A yes/no query should only be used when there is clear and consistent documentation of a condition/diagnosis in the health record, and the query is seeking confirmation or denial of a specific fact or detail related to that condition/diagnosis. A multiple-choice, open-ended, or verbal query may be more appropriate to allow the provider to choose from a list of possible diagnoses, provide additional information, or explain the clinical reasoning behind the documentation. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice 3

According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023, the principal diagnosis is defined as " the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care " 2 . In this case, the patient was admitted with shortness of breath, productive yellow sputum, and a temperature of 101.2, which are signs and symptoms of pneumonia. The CXR confirmed the diagnosis of LLL pneumonia, which is a serious condition that requires inpatient care. Therefore, LLL pneumonia is the principal diagnosis.

The secondary diagnoses are defined as " all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay " 2 . In this case, the patient had bilateral pleural effusion and kidney failure at the time of admission, which are coexisting conditions that affect the treatment received and/or the length of stay. The renal consult documented AKI with ATN, which is a more specific diagnosis than kidney failure and reflects the severity and etiology of the condition. Therefore, AKI with ATN and bilateral pleural effusion are secondary diagnoses.

References :

CDI Week 2020 Q & A: CDI and key performance indicators 1

ICD-10-CM Official Guidelines for Coding and Reporting FY 2023 2

The oversight committee is responsible for establishing the policies, procedures, and guidelines for the CDI program, as well as monitoring its performance and outcomes. The oversight committee should include representatives from senior leadership, medical staff, coding, quality, compliance, and other relevant stakeholders. The oversight committee should determine the chain of command that will be used to manage physicians who are either unresponsive or uncooperative with the CDI program, as well as the consequences for non-compliance. The other committees are not directly involved in setting the chain of command or the disciplinary actions for the CDI program. The communications committee is responsible for facilitating the information flow and feedback among the CDI staff, providers, coders, and other departments. The operations committee is responsible for managing the day-to-day activities and functions of the CDI staff, such as staffing, training, productivity, and workflow. The compliance committee is responsible for ensuring that the CDI program adheres to the ethical and legal standards and regulations, such as query compliance, documentation integrity, and privacy and security.

When queries are part of the health record, which is recommended by AHIMA and ACDIS, physicians are responsible for responding to queries in a timely manner and ensuring that their documentation is complete and accurate. If a provider receives too many deficiencies due to incomplete records for failure to respond to queries, their admitting privilege could be suspended by the medical staff committee as a disciplinary action.

References : AHIMA/ACDIS. “Guidelines for Achieving a Compliant Query Practice (2019 Update).” Journal of AHIMA 90, no. 2 (February 2019): 20-29.

According to the AHIMA CDIP Exam Preparation Guide, the adjusted case mix index (CMI) is a measure that demonstrates the relative severity and complexity of patients treated in a hospital, and is used to evaluate the financial impact of a hospital’s clinical documentation integrity (CDI) program 1 .  The adjusted CMI is calculated by multiplying the unadjusted CMI by a factor that accounts for the percentage of Medicare patients in the hospital 2 .  The higher the adjusted CMI, the higher the expected reimbursement per patient, and the more effective the CDI program is assumed to be 3 . The other options are not correct because they do not measure the severity and complexity of patients or the financial impact of CDI.  Hospital acquired conditions (HACs) are conditions that are not present on admission and are considered preventable by CMS, and may result in reduced reimbursement or penalties 4 . The program for evaluating payment patterns electronic report (PEPPER) is a report that provides hospital-specific data on potential overpayments or underpayments for certain services or diagnoses, and helps identify areas of risk or opportunity for improvement. Present on admission (POA) indicators are codes that indicate whether a condition was present at the time of admission or acquired during the hospital stay, and affect the assignment of DRGs and HACs.  References :

CDIP Exam Preparation Guide - AHIMA

Demystifying and communicating case-mix index - ACDIS

What is Case Mix Index? | The Importance of CMI

Hospital-Acquired Conditions (HACs) | CMS

[PEPPER Resources]

[Present on Admission Reporting Guidelines - CMS]

A CDI program’s vision should reflect its purpose, values, and goals, and align with the organization’s overall vision and mission. Value and mission statements help define the CDI program’s role, scope, and objectives, and communicate them to stakeholders. Reporting and the use of technology are important tools for a CDI program, but they are not part of its vision. Benchmarks and case mix index are performance indicators that measure the CDI program’s outcomes, but they do not reflect its vision. Diagnostic related groups and revenue cycle are aspects of reimbursement that may be affected by the CDI program, but they are not the primary focus of its vision.

A noncompliant multiple-choice query is one that does not include at least four options because it may limit the provider’s choice and suggest a preferred answer. A compliant multiple-choice query should include at least four options that are clinically significant, reasonable, and plausible based on the clinical indicators and documentation in the health record. The options should also be listed in alphabetical order to avoid any bias or preference. A compliant multiple-choice query should also allow the provider to add their own response if none of the options are appropriate, and include the option of “unable to determine” if the provider cannot make a definitive diagnosis based on the available information. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

Guidelines for Achieving a Compliant Query Practice (2019 Update) 3

The best place for the provider to document a query response is the next progress note and the problem list because this ensures that the query response is timely, consistent, and integrated into the health record.  According to the AHIMA/ACDIS query practice brief 1 , the provider should document the query response in the health record as soon as possible after receiving the query, preferably in the next progress note. The provider should also update the problem list to reflect any new or revised diagnoses resulting from the query response. This helps to maintain an accurate and comprehensive list of the patient’s current and chronic conditions, which can facilitate continuity of care, quality reporting, and reimbursement. Documenting the query response in an addendum to the history and physical or only on the query form is not sufficient, as it may not capture the current status of the patient or be easily accessible to other providers or coders.

References :

CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)

Guidelines for Achieving a Compliant Query Practice—2022 Update 1

  According to the Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA 1 , clinical validation is a process by which documentation is evaluated to ensure that the medical record demonstrates enough clinical support for all documented diagnoses as mandated by the False Claims Act. If there is a lack of clinical support for sepsis or UTI within the documentation, a clinical validation query should be sent. Query choices should list sepsis or UTI as ruled out versus ruled in (because the physician is documenting sepsis or UTI), but the query choice should also ask the provider to provide additional clinical support within the medical record.  Additional query choices that are supported by clinical indicators listed on the query should also be listed as appropriate 1 .

In this case, the patient was admitted with a fever, cough, and leukocytosis, which are signs and symptoms of sepsis or UTI. However, 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, which are indicators that sepsis or UTI may not be present or resolved. Therefore, there is a discrepancy between the documented diagnoses of sepsis and UTI and the clinical evidence in the record. A clinical validation query should be sent to clarify if sepsis and UTI are still valid diagnoses or if they have been ruled out after study.  The query should also request additional documentation of any other clinical indicators that support the diagnosis of sepsis or UTI, such as vital signs, physical exam findings, inflammatory markers, imaging results, etc 1 .

References :

Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA 1

Administration should respond to this situation by reviewing the record to determine any potential data integrity impact and/or rebilling implications. According to the AHIMA Practice Brief on Managing an Effective Query Process, post-bill queries are generally initiated as a result of an audit or other internal monitor, and healthcare entities can develop a policy regarding whether they will generate post-bill queries and the timeframe following claims generation that queries may be initiated.  The practice brief also states that healthcare entities should consider the following three concepts in the development of a post-bill (including query) policy: applying normal course of business guidelines, using payer-specific rules on rebilling timeframes, and determining reliability of query response over time  2 . Therefore, administration should review the record to see if the physician’s response to the query affects the quality of care, patient safety, severity of illness, risk of mortality, or reimbursement, and if so, whether it is appropriate and feasible to rebill the account based on the payer’s rules and the normal course of business guidelines. Administration should also evaluate the reasons for the physician’s delayed response and provide feedback and education to prevent future occurrences.

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  133  3   2 : AHIMA Practice Brief: Managing an Effective Query Process  4

A query should be generated when documentation contains a diagnosis without clinical validation, meaning that there is no evidence in the health record to support the diagnosis or that the diagnosis is inconsistent with other clinical indicators. A diagnosis without clinical validation may affect the accuracy and completeness of coding, quality measures, reimbursement, and patient care.

References : AHIMA/ACDIS. “Guidelines for Achieving a Compliant Query Practice (2019 Update).” Journal of AHIMA 90, no. 2 (February 2019): 20-29.

A noncompliant query includes querying the provider regarding gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators because it may lead to over-specification of a diagnosis that is not supported by the health record. A compliant query should be based on the clinical evidence and documentation in the record, and should not suggest or imply a diagnosis that is not clinically relevant or plausible. A query should also not be driven by reimbursement or coding factors, but by the need to improve the quality and accuracy of documentation. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

Guidelines for Achieving a Compliant Query Practice (2019 Update) 3

According to the AHIMA/ACDIS Query Practice Brief, one of the scenarios that warrants a query is when there is clinical evidence of a higher degree of specificity or severity 1 . In this case, the patient’s COPD exacerbation and oxygen therapy may indicate a higher level of respiratory impairment than chronic respiratory failure alone. Therefore, a query to the provider to see if acute on chronic respiratory failure is supported by the health record is appropriate and compliant.  Acute on chronic respiratory failure is a more specific and severe diagnosis that may affect the patient’s severity of illness, risk of mortality, and reimbursement 2 . The other options are not correct because they either assume a diagnosis without querying the provider, or query for a less specific or severe diagnosis than what the clinical indicators suggest.  References :

Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

Q & A: Respiratory failure in a drug overdose | ACDIS

When benchmarking with outside organizations, the clinical documentation integrity practitioner (CDIP) must determine if the organization is benchmarking with hospitals that are its peers because peer hospitals have similar characteristics such as size, location, teaching status, case mix index, and payer mix. Benchmarking with peer hospitals allows for a more accurate and meaningful comparison of performance indicators and outcomes. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2