AHIMA CDIP Value Pack (Frequently Bought Together)

When writing a compliant query, best practice is to

• A. direct the physician to a specific diagnosis
• B. use the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present
• C. include all relevant clinical indicators
• D. use a yes/no query format for specificity of a diagnosis

A 100-year-old female presents to the emergency department with altered mental state and a 3-day history of productive cough, shortness of breath, and fever after a witnessed aspiration 3 days ago. The patient lives in custodial care at a nearby skilled nursing facility. Patient was treated with Augmentin at the facility without improvement. Exam is notable for Tc 38.9, blood pressure 142/78, respiratory rate 28, pulse 91. There is accessory muscle use with breathing.
Patient is moaning and disoriented but
otherwise the neurologic exam is nonfocal.
Labs notable for sodium 126, creatinine 0.5. white blood count 17.5, hemoglobin 13, platelet 200. venous blood gas 7.44/32/45/-3 Chest x-ray shows bilateral lower lobe infiltrates and dense right lower lobe consolidation.
Patient is placed on bilevel positive airway pressure and given vancomycin, pip/tazo, levofloxacin.
Discharge Diagnosis: health care associated pneumonia (HCAP), respiratory distress, altered mental status, low sodium Which list of diagnoses require a post-discharge query that will result in a more specific principal diagnosis with the highest level of severity of illness and risk of mortality?

• A. Coma, stroke, HCAP, hypernatremia
• B. Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure
• C. Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia
• D. Severe sepsis, hypernatremia, delirium, pneumonia

A clinical documentation integrity practitioner (CDIP) in an acute care hospital was asked to create new query templates for ICD-10 based on AHIMA and ACDIS guidelines. What should the multiple-choice query format include?

• A. Clinically unsupported diagnosis
• B. Clinically insignificant options
• C. Clinically significant options
• D. Impact on reimbursement

A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is

• A. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
  Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment.
• B. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.
• C. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.
• D. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
  Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other.

A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?

• A. Gather data on the incidence of inaccurate record documentation
• B. Bring together a team of physicians and informatics specialists
• C. Alert senior leadership to the record documentation problem
• D. Recommend the physicians to be involved in the project