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Which member of the clinical documentation integrity (CDI) team can help provide peer-to-peer level of education on the importance of accurate documentation and query responses?
Which member of the clinical documentation integrity (CDI) team can help provide peer-to-peer level of education on the importance of accurate documentation and query responses?A . Chief Financial OfficerB . Physician advisor/championC . CDI practitionerD . CDI managerView AnswerAnswer: B Explanation: The member of the clinical documentation integrity (CDI) team...
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Review the following query to determine if it is compliant: Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated? Dehydration Hyponatremia Hypernatremia Chronic kidney disease (indicate stage) Other (please specify)A ....
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 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...
A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs: BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia. Aspiration precautions and IV Clindamycin ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.
A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs: BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs:...
When are concurrent queries initiated?
When are concurrent queries initiated?A . After the health record has been codedB . After discharge of the patientC . While the patient is hospitalizedD . Before patient is admittedView AnswerAnswer: C
Which policy and procedure should be developed to ensure compliant practice?
Several physicians at a local hospital are having difficulty providing adequate documentation on patients admitted with a diagnosis of pneumonia with or without clinical indications of gram-negative pneumonia. Subsequently, clinical documentation integrity practitioners (CDIPs) are altering health records. Which policy and procedure should be developed to ensure compliant practice?A ....
A modifier may be used in CPT and/or HCPCS codes to indicate
A modifier may be used in CPT and/or HCPCS codes to indicateA . a service or procedure was increased or reducedB . a service or procedure was performed in its entiretyC . a service or procedure resulted in expected outcomesD . a service or procedure was performed by one providerView...
Which of the following queries is presented in an ethical manner thus avoiding potential fraud and/or compliance issues?
An 86-year-old female is brought to the emergency department by her daughter. The patient complains of feeling tired, weak and excessive sleeping. The patient's daughter comments that patient's mental condition has not been the same. Lab results are unremarkable except for a sodium level of 119, a BUN of 22,...
The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is
The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction isA . 05HM33Z Insertion of infusion device into right internal jugular vein, percutaneous approachB . 02H633Z Insertion of infusion device into right atrium, percutaneous approachC . 05HP33Z...
