CLINICAL DOCUMENTATION EXAM 6
|HEALTH RECORDS SPECIALIST | LATEST
2025-2026 QUESTION AND CORRECT ANSWER
WITH EXPLANATION WEST COAST
UNIVERSITY
Question 1
A payer denies a claim stating “sepsis not supported by documentation.”
The chart includes infection, hypotension, and elevated lactate, but no
explicit “sepsis” diagnosis. What is the best CDI interpretation?
A. Denial is correct; sepsis cannot be inferred
B. Sepsis may be clinically supported but not explicitly documented;
requires provider query
C. Code sepsis regardless of documentation
D. Code infection only
Correct Answer: B
Rationale: CDI must not assume diagnosis; sepsis requires provider
confirmation even if clinical indicators exist.
Question 2
During audit review, a CDI specialist finds that “acute respiratory failure”
was coded based solely on low oxygen saturation (92%) without
respiratory distress or intervention. What is the most appropriate
conclusion?
A. Coding is fully supported
B. Respiratory failure is unsupported and potentially invalid
C. Diagnosis is automatically valid
D. Oxygen saturation alone confirms respiratory failure
Correct Answer: B
Rationale: Mild hypoxemia alone does not meet criteria for respiratory
failure.
Question 3
A provider documents “septic shock” but vasopressors were never
administered and BP stabilized with IV fluids alone. What is the CDI risk?
,A. Accurate diagnosis
B. Overcoding due to lack of shock criteria
C. Underreporting severity
D. No compliance issue
Correct Answer: B
Rationale: Septic shock requires persistent hypotension requiring
vasopressors.
Question 4
A CDI audit reveals frequent copy-paste documentation across multiple
inpatient days. What is the primary compliance concern?
A. Faster documentation
B. Risk of perpetuating inaccurate clinical data
C. Improved continuity
D. Better coding accuracy
Correct Answer: B
Rationale: Copy-paste increases risk of propagating outdated or
incorrect clinical information.
Question 5
A provider documents “probable pneumonia” in outpatient notes, and
antibiotics were prescribed. What is correct coding action?
A. Code pneumonia
B. Code probable pneumonia
C. Code symptoms only
D. Ignore antibiotics
Correct Answer: C
Rationale: Outpatient settings require confirmed diagnoses; only
symptoms are coded if uncertain.
Question 6
A payer requests validation for MS-DRG assignment. Which
documentation is MOST critical?
, A. Room number
B. Principal diagnosis and supporting comorbidities
C. Insurance authorization
D. Admission time
Correct Answer: B
Rationale: DRG validation depends on clinical diagnoses and
complications.
Question 7
A chart shows “acute encephalopathy” without lab abnormalities, toxic
exposure, or metabolic cause. What is the CDI concern?
A. Overdocumentation
B. Lack of clinical etiology
C. Duplicate diagnosis
D. Valid standalone diagnosis
Correct Answer: B
Rationale: Encephalopathy requires an identifiable cause for coding
validity.
Question 8
Which scenario is MOST likely to trigger payer denial for sepsis?
A. Elevated WBC and fever
B. Infection with organ dysfunction
C. Infection without organ dysfunction or lactate elevation
D. Positive blood cultures with hypotension
Correct Answer: C
Rationale: Sepsis requires organ dysfunction; infection alone is
insufficient.
Question 9
A CDI specialist finds conflicting documentation between discharge
summary (CHF exacerbation) and progress notes (fluid overload only).
What should be done?
|HEALTH RECORDS SPECIALIST | LATEST
2025-2026 QUESTION AND CORRECT ANSWER
WITH EXPLANATION WEST COAST
UNIVERSITY
Question 1
A payer denies a claim stating “sepsis not supported by documentation.”
The chart includes infection, hypotension, and elevated lactate, but no
explicit “sepsis” diagnosis. What is the best CDI interpretation?
A. Denial is correct; sepsis cannot be inferred
B. Sepsis may be clinically supported but not explicitly documented;
requires provider query
C. Code sepsis regardless of documentation
D. Code infection only
Correct Answer: B
Rationale: CDI must not assume diagnosis; sepsis requires provider
confirmation even if clinical indicators exist.
Question 2
During audit review, a CDI specialist finds that “acute respiratory failure”
was coded based solely on low oxygen saturation (92%) without
respiratory distress or intervention. What is the most appropriate
conclusion?
A. Coding is fully supported
B. Respiratory failure is unsupported and potentially invalid
C. Diagnosis is automatically valid
D. Oxygen saturation alone confirms respiratory failure
Correct Answer: B
Rationale: Mild hypoxemia alone does not meet criteria for respiratory
failure.
Question 3
A provider documents “septic shock” but vasopressors were never
administered and BP stabilized with IV fluids alone. What is the CDI risk?
,A. Accurate diagnosis
B. Overcoding due to lack of shock criteria
C. Underreporting severity
D. No compliance issue
Correct Answer: B
Rationale: Septic shock requires persistent hypotension requiring
vasopressors.
Question 4
A CDI audit reveals frequent copy-paste documentation across multiple
inpatient days. What is the primary compliance concern?
A. Faster documentation
B. Risk of perpetuating inaccurate clinical data
C. Improved continuity
D. Better coding accuracy
Correct Answer: B
Rationale: Copy-paste increases risk of propagating outdated or
incorrect clinical information.
Question 5
A provider documents “probable pneumonia” in outpatient notes, and
antibiotics were prescribed. What is correct coding action?
A. Code pneumonia
B. Code probable pneumonia
C. Code symptoms only
D. Ignore antibiotics
Correct Answer: C
Rationale: Outpatient settings require confirmed diagnoses; only
symptoms are coded if uncertain.
Question 6
A payer requests validation for MS-DRG assignment. Which
documentation is MOST critical?
, A. Room number
B. Principal diagnosis and supporting comorbidities
C. Insurance authorization
D. Admission time
Correct Answer: B
Rationale: DRG validation depends on clinical diagnoses and
complications.
Question 7
A chart shows “acute encephalopathy” without lab abnormalities, toxic
exposure, or metabolic cause. What is the CDI concern?
A. Overdocumentation
B. Lack of clinical etiology
C. Duplicate diagnosis
D. Valid standalone diagnosis
Correct Answer: B
Rationale: Encephalopathy requires an identifiable cause for coding
validity.
Question 8
Which scenario is MOST likely to trigger payer denial for sepsis?
A. Elevated WBC and fever
B. Infection with organ dysfunction
C. Infection without organ dysfunction or lactate elevation
D. Positive blood cultures with hypotension
Correct Answer: C
Rationale: Sepsis requires organ dysfunction; infection alone is
insufficient.
Question 9
A CDI specialist finds conflicting documentation between discharge
summary (CHF exacerbation) and progress notes (fluid overload only).
What should be done?
