CDIP 2023 Exam Questions With Complete Solutions

CDIP 2023 Exam Questions With Complete Solutions CDI program data includes: - CORRECT ANSWERS 1. All cases that were reviewed 2. Number of cases with queries 3. Nature of the query 4. Physician response to the query Queries should only be asked: - CORRECT 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: - CORRECT 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. Examples of when a query is required may include: - CORRECT 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. Septicemia - CORRECT ANSWERS A systemic disease with the presence and persistence of pathogenic micro-organisms or toxins in the blood. No longer considered synonymous with sepsis. Sepsis - CORRECT 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. Severe Sepsis - CORRECT ANSWERS SIRS due to infection with organ dysfunction. Sepsis associated with acute dysfunction in one or more organs. Organ dysfunction bay be cardiovascular, renal, respiratory, hepatic, hematological, central nervous system, or metabolic acidosis. SIRS - CORRECT ANSWERS SIRS is the systemic response to infection or trauma. The systemic response is manifested by a variety of clinical signs and symptoms such as: Fever (>100.4 degrees F), Hypothermia (<96.8 degrees F), WBC >= to 12000 cellsmm3 (leukocytosis), WBC <= to 4000 cells/mm3 or 10% immature cells, heart reat >90 bpm, respirations >20 breaths/minute or PcCO2 <32 mg of mercury, hypotension, altered mental status. Septic Shock - CORRECT ANSWERS Sepsis with hypotension or a failure of the cardiovascular system. Endotoxic shock and gram negative shock are synomymous with septic shock, septic shock = severe sepsis Bacteremia - CORRECT ANSWERS Bacteria in the blood without an associated inflammatory response. Denotes laboratory findings of viable bateria in the blood with no systemic manifestations. Progresses to septicemia only when there is a more severe infections process or an impaired immune system. Urosepsis - CORRECT ANSWERS Infection confined to the urinary system. Refers to pyuria or bacteria in the urine (not in the blood). Query the physician to determine if the bacteria in the urine has progressed to septicemia or sepsis. 7 criteria for high-quality documentation - CORRECT ANSWERS Legible Complete Timely Reliable Consistent Precise Clear EBM - CORRECT ANSWERS Evidence Based Medicine-practicing medicine using only the best scientific data available. Four kinds of standards in EBM - CORRECT ANSWERS Design Performance Terminology Procedural Theory of high-quality of clinical documentation - CORRECT ANSWERS If the 7 criteria of high-quality clinical documentation are applied ot clinical documentation, then clinical documentation quality will be high and the accuracy of care, quality indicators, reimbursement, healthcare planning, and research will be improved. What year was TEFRA (Tax Equity and Fiscal Responsibility Act) implemented? - CORRECT ANSWERS 1982 DRGs - CORRECT ANSWERS Developed by Yale in the 70's to describe all types of patient care in an acute care hospital. Implemented for Medicare IPP in 1983. AP-DRGs - CORRECT ANSWERS Implemented in 1987 by 3m. For NY non-Medicare discharges reimbursement program.