100% Correct Answers | Latest Update
Clinical Documentation Improvement (CDI) programs can help: - 🧠
ANSWER ✔✔- Build effective documentation compliance policies
- Capture clinical data required for continuity of care
documentation deficiency that has a negative impact on patient outcomes -
🧠 ANSWER ✔✔Failure to include the complications of drug for
prescriptions taken by a patient.
What is best practice to communicate document deficiencies to a provider?
- 🧠 ANSWER ✔✔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: -
🧠 ANSWER ✔✔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: - 🧠 ANSWER ✔✔- Evidence based
medicine
- Financial motive
- Malpractice liability
- Documentation impact on reimbursement
- Documentation impact on compliance
Which EMR feature is non-compliant with CMS? - 🧠 ANSWER
✔✔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? - 🧠
, ANSWER ✔✔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? - 🧠 ANSWER ✔✔Increase reimbursements
CDI programs can help with: - 🧠 ANSWER ✔✔Consistency of
documentation & Team building
Which is NOT an acceptable cause for query? - 🧠 ANSWER ✔✔Signs and
symptoms without a diagnosis
Which is a leading query? - 🧠 ANSWER ✔✔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: - 🧠 ANSWER ✔✔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: - 🧠 ANSWER ✔✔Can you please
address the patient's potassium status in further detail?
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