Clinical Documentation Improvement (CDI) programs can help: - - Build effective documentation compliance policies
- Capture clinical data required for continuity of care
documentation deficiency that has a negative impact on patient outcomes - Failure to include the complications of drug for pr...
CDEO STUDY GUIDE QUESTIONS AND
ANSWERS
Clinical Documentation Improvement (CDI) programs can help: - - Build effective
documentation compliance policies
- Capture clinical data required for continuity of care
documentation deficiency that has a negative impact on patient outcomes - Failure
to include the complications of drug for prescriptions taken by a patient.
What is best practice to communicate document deficiencies to a provider? -
Provide examples of the provider's documentation errors with suggestions for
improvement.
A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are
found with the diagnosis of marasmus. Your correct response: - Display in your
query the Index entry for marasmus and the codes and descriptions for E41 and
R54. Ask for guidance on which to report.
The best approach when querying a physician regarding documentation is to
approach the problem as one of: - - Evidence based medicine
- Financial motive
- Malpractice liability
- Documentation impact on reimbursement
- Documentation impact on compliance
,Which EMR feature is non-compliant with CMS? - Templates that allow the
provider to de-select a prepopulated "normal" checkmark when the system is
abnormal in the ROS
When providing CDI to a provider, does the message change depending on
whether you are performing a prospective or retrospective audit? - Yes, because the
auditor cannot ask leading questions regarding documentation before a claim is
submitted.
What is NOT considered a purpose of documentation improvement programs? -
Increase reimbursements
CDI programs can help with: - Consistency of documentation & Team building
Which is NOT an acceptable cause for query? - Signs and symptoms without a
diagnosis
Which is a leading query? - Your sarcoidosis patient has sarcoid lesions on the
cerebral cortex, correct?
The surgeon documents liver cancer, but the pathology report states angiosarcoma
of liver. You: - Code the liver cancer as angiosarcoma, a primary liver cancer,
based on the pathologist's documentation.
In reviewing the provider's assessment the documentation states "lab tests
reviewed: +K." You correctly query: - Can you please address the patient's
potassium status in further detail?
Documentation states:
, Patient has a history of a recent myocardial infarct and is admitted today with an
ST elevation MI of the anterior wall.
The flaw in this documentation from a coding standpoint: - The duration between
the recent myocardial infarct and the current myocardial infarct will impact coding,
so "recent" is insufficient documentation
Which term or phrase, when used between a manifestation and etiology, does NOT
always show a causal relationship? - likely
Which is an example of poor documentation that is especially problematic as there
is no "unspecified" code for the condition in ICD-10-CM? - Degenerative disc
disease (DDD)
When reviewing documentation and you notice information is missing, what is the
proper procedure? - The information should be added as a documented late
entry/addendum only when necessary.
Is it an acceptable practice to use a template that always documents a complete
review of systems? - No. The extent of ROS performed and documented is
dependent upon clinical judgment and the nature of the presenting problem(s).
Which type of documentation can be used to report diagnoses under risk
adjustment models? - Inpatient Admission Note
What type of payment does an ACO (Accountable Care Organization) receive? -
An ACO receives reimbursements based on quality metrics and reductions in the
total cost of care for an assigned population of patients.
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