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Automated registration entries that generate erroneous patient identification―possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit―is an example of a potential breach of:
Automated registration entries that generate erroneous patient identification―possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit―is an example of a potential breach of:A . Authorship integrityB . Patient identification and demographic accuracyC . Documentation integrityD ....
Which of the following is the definition of an Excludes 2 note in ICD-10-CM?
Which of the following is the definition of an Excludes 2 note in ICD-10-CM?A . Neither of the codes can be assignedB . Two codes can be used together to completely describe the conditionC . Only one code can be assigned to completely describe the conditionD . This is not...
How should administration respond in this situation?
Hospital policy states that physician responses to queries should be no longer than timely payer filing requirements. A physician responds to a query after the final bill has been submitted. How should administration respond in this situation?A . Evaluate the payer's timeframe for billing and reasons for the physician's delayed...
What is the unintended consequence of this?
An organization dealing with staffing shortages has adopted a policy requiring clinical documentation integrity practitioner (CDIP) to stop reviewing any record after a major complication or co-morbidity is found. What is the unintended consequence of this?A . Increase in case mix indexB . Reduced risk of clinical denialsC . Increased...
Which policy should the hospital follow to avoid a compliance risk?
A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped. Which policy...
Which of the following is an example of a hospital-acquired condition when not present on admission?
Which of the following is an example of a hospital-acquired condition when not present on admission? A. Iatrogenic pneumothorax with lung biopsy B. Iatrogenic pneumothorax with venous catheterization C. Pressure ulcer stage II D. Pressure ulcer stage IIIView AnswerAnswer: D Explanation: A hospital-acquired condition (HAC) is an undesirable situation or...
Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program?
Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program?A . Hospital acquired conditionsB . Program for evaluating payment patterns electronic reportC . Present on admission indicatorsD ....
Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?
A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs: BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed...
The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to
The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is toA . look for documented conditions that have well supported accompanying clinical criteriaB . determine if only the treatment is documented and there is no diagnosis documentedC . watch...
Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?
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...
