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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?
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?A . Multiple-choiceB . Open-endedC . VerbalD . Yes/NoView AnswerAnswer: D Explanation: A yes/no query may not be used in circumstances...
Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?
Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?A . LegibleB . CompleteC . ReliableD . PreciseView AnswerAnswer: C Explanation: According to AHIMA, clinical documentation is at the core of every patient encounter and it...
What is the best course of action for the clinical documentation integrity (CDI) physician advisor/champion?
The third quarter target concurrent physician query response rate for each physician in a hospital gastroenterology department was 80%. Nine physicians met or exceeded this metric; however, two physicians had third quarter concurrent physician query response rates of 19% and 64%. What is the best course of action for the...
Which of the following falls under the False Claims Act?
Which of the following falls under the False Claims Act?A . Missing chargesB . Unbundling servicesC . Missing modifiersD . Missing diagnosis codesView AnswerAnswer: B Explanation: Unbundling services falls under the False Claims Act because it is a form of coding fraud that involves billing separately for components of a...
What can the manager do to ensure program success?
After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?A . Expand the CDI program to larger areas in outpatient clinicsB ....
The correct coding for heart failure with preserved ejection fraction is
The correct coding for heart failure with preserved ejection fraction isA . 150.32 Chronic diastolic (congestive) heart failureB . I50.20 Unspecified systolic (congestive) heart failureC . I50.9 Heart failure, unspecifiedD . I50.30 Unspecified diastolic (congestive) heart failureView AnswerAnswer: D Explanation: According to the ICD-10-CM Official Guidelines for Coding and Reporting...
physicians in a hospital?
In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?A . The latest Medicare Provider and Analysis Review dataB . Emphasize the Medicare requirements for documentationC . Examples...
What can be done to improve this rate?
The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?A . Have CDI manager teaming with coding supervisor to monitor physician responsesB . Require physicians to...
When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?
When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?A . Physician and CDIP interactionB . Coder and CDIP interactionC . Executive oversightD...
What is the next step the CDIP should take?
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...
