Pass the AHIMA Documentation Integrity Practitioner (CDI) CDIP Questions and answers with ExamsMirror

The ICD-10-CM 7th character code value should indicate aftercare for a patient who falls off a ladder and undergoes a right femur procedure, and then returns to the hospital for removal of the external fixation device. Aftercare codes are used to capture encounters for follow-up care after completed treatment of an injury or condition, such as removal of external fixation devices, casts, or pins. Aftercare codes are not used for subsequent encounters for complications or infections related to the injury or condition5 References: 1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf  5: https://my.ahima.org/store/product?id=67077

Reviewing and analyzing physician query content on a regular basis assists in identifying gaps in skills and knowledge of the clinical documentation integrity practitioners (CDIPs) and the providers. By evaluating the quality, accuracy, appropriateness, and effectiveness of the queries, the CDIPs can identify areas of improvement, education, and feedback for themselves and the providers. Reviewing and analyzing physician query content can also help to ensure compliance with industry standards and best practices, as well as to monitor query outcomes and trends2 References: 1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf  2: https://my.ahima.org/store/product?id=67077

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 Rule1, 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 Rule1

According to the AHIMA/ACDIS Query Practice Brief, one of the best practices for a compliant query process is to provide ongoing education to physicians on the importance of documentation integrity, the query process, and the impact of documentation on quality measures, reimbursement, and compliance1. Education can help physicians understand the rationale and expectations for responding to queries, as well as the benefits of accurate and complete documentation for patient care and data quality. Education can also address any barriers or challenges that physicians may face in responding to queries, such as time constraints, technology issues, or workflow preferences1. References:

AHIMA/ACDIS Query Practice Brief – Updated 12/2022

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

 According to the Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1, 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 appropriate1.

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, etc1.

References:

Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1

According to the AHIMA best practice for written queries, queries should be limited to non-leading questions that do not imply a specific answer or diagnosis, but rather ask for the provider’s opinion based on their clinical judgment and the evidence in the health record. Non-leading questions help to ensure that the query is compliant, objective, and respectful of the provider’s authority and autonomy. Leading questions, on the other hand, may introduce bias, influence the provider’s response, or compromise the integrity of the documentation and coding. For example, a non-leading query for a patient with chest pain would be: “What is the etiology of the chest pain?” A leading query would be: “Is the chest pain due to acute myocardial infarction?”

References:

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

Guidelines for Achieving a Compliant Query Practice—2022 Update1

A query is noncompliant if it includes options that are not supported by the clinical indicators or the patient’s condition. In this case, hypernatremia is a condition of high sodium level, not low sodium level, and it is not consistent with the treatment of 0.9% saline IV. Therefore, it is a clinically irrelevant option that may confuse or mislead the provider. A compliant query should only include options that are reasonable and plausible based on the available documentation and evidence. (CDIP Exam Preparation Guide)

References:

CDIP Exam Content Outline1

CDIP Exam Preparation Guide2

AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3

A physician advisor/champion is a physician leader who supports and advocates for the CDI program and its objectives. A physician advisor/champion can help overcome the objections of other physicians by providing education, feedback, guidance, and mentorship on documentation best practices and their impact on revenue, quality, and patient care. A physician advisor/champion can also act as a liaison between the CDI firm and the medical staff, resolve conflicts or discrepancies in documentation, and foster a culture of collaboration and improvement. Physicians are more likely to trust and engage with their peers who understand their clinical perspective and challenges, rather than an external CDI firm that may be perceived as intrusive or disruptive.

A. Create a vision statement that outlines the project objectives. This is not sufficient to collaborate with physicians and overcome their objections. A vision statement is a general statement that describes the desired outcome of the project, but it does not address the specific concerns or questions that physicians may have about the CDI firm’s role, methods, or benefits.

B. Communicate the benefits of the CDI firm about the project. This is not enough to collaborate with physicians and overcome their objections. Communicating the benefits of the CDI firm may be informative, but it may not be persuasive or credible if it comes from the CDI firm itself, without any endorsement or support from a physician leader within the organization.

C. Hire a consultant to communicate the benefits to the physicians. This is not a good way to collaborate with physicians and overcome their objections. Hiring a consultant may add another layer of complexity and cost to the project, and it may not improve the trust or relationship between the CDI firm and the physicians. A consultant may also lack the clinical expertise or authority to influence the physicians’ behavior or attitude.

References:

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

Q&A: Defining roles for physician advisor/champion | ACDIS

Q&A: The Role of the Physician Advisor in CDI | ACDIS

The Role of a Physician Advisor - UASI Solutions

PA/NP in Physician Champion / Advisor Role — ACDIS Forums

The abbreviation NEC stands for “not elsewhere classified” and is used in the ICD-10-CM Alphabetical Index when a specific code is not available for a condition. The coder should use the NEC notation to locate the closest existing code that matches the documented diagnosis. For example, if the physician documented a malignant neoplasm of the left upper eyelid, but the Alphabetical Index only has an entry for malignant neoplasm of eyelid NEC, then the coder should use the code C44.10 (Unspecified malignant neoplasm of unspecified eyelid, including canthus) and assign a seventh character to specify laterality. (CDIP Exam Preparation Guide)

References:

CDIP Exam Content Outline1

CDIP Exam Preparation Guide2

ICD-10-CM Official Guidelines for Coding and Reporting FY 20213