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1. Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?
A) The query is leading.
B) The query contains irrelevant information.
C) The query does not contain clinical indicators.
D) The query is unclear.
2. Which of the following can be evidence of physician-hospital alignment?
A) A low physician agreement rate
B) A high physician agreement rate
C) A high physician response rate
D) A high clinical documentation integrity practitioner (CDIP) query rate
3. Which of the following is used to measure the impact of a clinical documentation integrity (CDI) program on Centers for Medicare and Medicaid Services quality performance?
A) Outcome measures
B) Risk of mortality
C) Case mix index
D) Severity of illness
4. Which of the following is a clinical documentation element supporting a transbronchial biopsy?
A) Pathology report documenting alveolar tissue
B) Length of procedure
C) Pathology report documenting bronchial tissue
D) Hemoptysis
5. A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?
A) Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)
B) Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
C) Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
D) Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient's morbid obesity was present on admission and add the diagnosis to future progress notes?
Solutions:
| Question # 1 Answer: A | Question # 2 Answer: B | Question # 3 Answer: A | Question # 4 Answer: A | Question # 5 Answer: A |
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