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CDIP(clinical documentation improvement )New!!!

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Examples of when a query is required may include: - answers-1. Documentation of reportable conditions or procedures is conflicting, ambigious, or is otherwise incomplete. 2. Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or higher specificity of an already...

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  • February 19, 2024
  • 7
  • 2023/2024
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CDIP(clinical documentation improvement )New!!! Examples of when a query is required may include: - answers-1. Documentation of reportable conditions or procedures is conflicting, ambigious, or is otherwise incomplete.
2.Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or higher specificity of an already documented condition.
3.The patient is receiving treatment for a condition that has not been documented.
4.Abnormal operative or procedureal findings are not documented.
5.It is unclear as to whether a condition was ruled out.
6.The pricipal diagnosis is not clearly identified.
Four kinds of standards in EBM - answers-Design Performance Terminology Procedural
Heart Disease Tests - answers-Electrocardiogram (ECG), Echocardiogram, stress tests, chest x-ray, nuclear imaging, CAT scan (SPECT), cardiac cauterization, angiography, doppler studies, blood tests, arterial blood gas
How to calculate CMI - answers-Sum of all of the DRG's relative weights/# of cases per time period
Key Facts to CMI - answers-Two Major Factors with IPPS DRGs and CMI:
-Medical record documentation
-Coding Changes
Changes in documentation and/or coding practices will affect the DRG assignment and thus the CMI
Changes in the coding process for translating the diagnostic information into standard codes likewise affects DRG assignment.
Levels of DRGS in each system: AP-DRGs - answers-Stand alone DRGs (TIA), without a CC, with a CC, with a MCC.
Levels of DRGS in each system: APR DRGs - answers-No stand alone DRGs, severity 1 (minor), severity 2 (moderate), severity 3 (major), severity 4 (extreme).
Levels of DRGS in each system: MS-DRGs - answers-Stand alone DRGs (TIA), without a CC, with a CC, with a MCC.
Lifestyle Modifications Heart Disease Tx - answers-Dietary modification, exercise, smoking cessation
MCC/CC conditions consist of: - answers-Significant acute diseases, acute exacerbations of chronic significant diseases, advanced end-stage diseases, chronic diseases with extensive debility, consistnely greater impact on hospital resources. MCE - answers-Medicare Code Editor-Addresses 3 basic types of edits that support MS-DRG assignment which are code edits, coverage edits, and clinical edits.
MS-DRGs MCC/CC List - answers-MCC/CC conditions consist of: Significant acute diseases
Acute exacerbations of chronic significant diseases Advanced end stage diseases
Chronic diseases with extensive debility Consistenly greater impact of hospital resources
Pateint has HIV and disseminated candidiasis, what is the correct code assignment? - answers-042-Human Immunodeficiency Virus (HIV) Disease
112.5-Candidiases, Disseminated
POA Indicators and Definitions - answers-Y = Present at the time of inpatient admission N = Not present at the time of inpatient admission
U = documentation is insufficient to determine if conditions is present on admission W = provider is unable to clinically determine whether condition was present on admission or not
PPS Examples - answers-Acute inpatient PPS (IPPS): DRGs Hospital Outpatient PPS (OPPS): APCs
Home Health PPS (HH PPS): OASIS
Skilled Nursing Facility PPS (SNF PPS): MDS Inpatient Rehabilitation Facility (IRF PPS): PAI
Queries should only be asked: - answers-1. If there is clinical evidence that the documentation is imcomplete or does not meet one of the seven criteria for high-quality clinical documentation.
2.By an individual with solid clinical knowledge.
3.In an open-ended manner (no yes or no questions)
4.In a nonleading manner.
5.To the individual whose documentaion is in question or who is responible for interpreting test results or other data in the patient's record.
Query process and procedure should address: - answers-1. When queries will be asked.
2.Who will ask queries and to whom queries will be asked.
3.The hospital's responsibility in supporting the quering process.
4.The physician's responsibility in responding to queries.
5.Acceptable ways to responding to queries.
Sepsis - answers-Sepsis is SIRS due to an infection . Infection can originate anywhere in the body and be triggered by a bacterial, viral, parasitic, or fungal infection.
Sepsis Tests - answers-Organ function studies - Kidney, liver, etc.

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