Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?
Correct Answer:
C
According to AHIMA, clinical documentation is at the core of every patient encounter and it must be meaningful to accurately reflect the patient??s disease burden and scope of services provided. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible1. Reliability is one of the criteria for clinical documentation that means the content of the record is trustworthy, safe, and yielding the same result when repeated1. Reliability ensures that the documentation is consistent with the clinical evidence and reasoning, and that it can be verified by other sources or methods. Reliability also implies that the documentation is free from errors, omissions, contradictions, or ambiguities that could compromise its validity or usefulness1. References:
✑ Clinical Documentation Integrity Education & Training | AHIMA1
A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate
time frame. What should the CDIP do next?
Correct Answer:
A
According to the AHIMA-ACDIS Practice Brief, a query escalation policy should describe how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, the department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for the organization1. In this case, since the attending physician has not responded to the query in an appropriate time frame, the CDIP should escalate the issue to the medical staff leadership, such as the chief medical officer, the department chair, or the physician advisor, who can facilitate communication and education with the attending physician and ensure documentation integrity and compliance1.
References:
✑ Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1
Which entity has the following regulation?
A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but
prior to surgery or a procedure requiring anesthesia services.
Correct Answer:
A
The entity that has the following regulation is the Centers for Medicare & Medicaid Services (CMS), which is the federal agency that oversees the Medicare and Medicaid programs and sets the Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) for health care organizations that participate in these programs. The regulation that requires a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, is part of the CoPs for Hospitals, which are located in 42 CFR ?? 482.24. This regulation was revised in 2007 to align with the Joint Commission??s standard and to provide more flexibility and consistency for hospitals and practitioners. (CDIP Exam Preparation Guide)
References:
✑ CDIP Exam Content Outline1
✑ CDIP Exam Preparation Guide2
✑ 42 CFR ?? 482.243
An organization dealing with staffing shortages has adopted a policy requiring clinical documentation integrity practitioner (CDIP) to stop reviewing any record after a major complication or co-morbidity is found. What is the unintended consequence of this?
Correct Answer:
D
Severity of illness (SOI) and risk of mortality (ROM) are two metrics that measure the complexity and acuity of a patient??s condition, based on the number, nature, and interaction of complications and comorbidities (CCs) and major CCs (MCCs). SOI reflects the extent of physiologic decompensation or organ system loss of function, while ROM reflects the likelihood of dying. Both SOI and ROM are divided into four levels: minor, moderate, major, or extreme. These metrics are used to adjust payment rates, quality indicators, and performance measures for hospitals and other healthcare providers.
If a CDIP stops reviewing any record after a major CC is found, they may miss other CCs or MCCs that could affect the patient??s SOI and ROM levels. For example, a patient with pneumonia and sepsis would have a major CC (pneumonia) and an MCC (sepsis). If the CDIP stops reviewing the record after finding pneumonia, they would not capture sepsis, which would increase the patient??s SOI and ROM levels from major to extreme. This would result in underreporting the patient??s true complexity and acuity, and potentially lead to lower reimbursement, lower quality scores, and higher denial risk.
Therefore, the unintended consequence of this policy is a decrease in SOI and ROM levels for patients who have more than one CC or MCC.
References:
✑ CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
✑ Q&A: Understanding SOI and ROM in the APR-DRG system
✑ 3M™ All Patient Refined Diagnosis Related Groups (APR DRGs)
✑ Severity of illness | definition of severity of illness by Medical dictionary
✑ Using Severity Adjustment Classification for Hospital Internal and External Comparisons
Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner's role within the organization?
Correct Answer:
D
Sharing the mission of the CDI program should be done to ensure a clear sense of what CDI is and the CDI practitioner??s role within the organization. The mission statement defines the purpose, goals, and values of the CDI program, and how it aligns with the organization??s vision and strategy. The mission statement also communicates the benefits and expectations of the CDI program to various stakeholders, such as providers, executives, coders, quality staff, and patients. The mission statement can help establish the credibility, professionalism, and identity of the CDI practitioners, and guide their daily activities and decisions 2.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: Mission CDI: Guiding goals, values, and principles 1
