The facility has received a clinical validation denial for sepsis. The denial states sepsis is not a clinically valid diagnosis because it does not meet Sepsis-3 criteria. The facility has a policy stating it uses Sepsis-2 criteria. What is the BEST next step?

1. A. Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.
2. B. Appeal the denial because all payors must use the hospital's sepsis criteria when reviewing their claims.
3. C. Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.
4. D. Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.

Correct Answer: D

The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program. The plan is to use case mix index (CMI) as a metric of CDI performance. How will this metric be measured?

1. A. Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI
2. B. Over time with a focus on particular documentation improvement areas in addition to the overall CMI
3. C. Month-to-month and focus on patient volumes to determine the raise the overall CMI
4. D. Month-to-month to show CMI variability as a barometer of a specific month

Correct Answer: B
CMI is a metric that reflects the diversity, complexity, and severity of the patients treated at a healthcare facility, such as a hospital. CMI is used by CMS to determine hospital reimbursement rates for Medicare and Medicaid beneficiaries. CMI is calculated by adding up the relative MS-DRG weight for each discharge, and dividing that by the total number of Medicare and Medicaid discharges in a given month and year. Higher CMI values indicate that a hospital has treated a greater number of complex, resource-intensive patients, and the hospital may be reimbursed at a higher rate for those cases.
However, CMI is not the best measure of CDI performance, because it is influenced by many factors beyond CDI efforts, such as patient population, coding accuracy, documentation specificity, patient comorbidities, high volumes of highly weighted DRGs, and annual updates to relative MS-DRG weights. Therefore, measuring CMI over time with a focus on particular documentation improvement areas in addition to the overall CMI can provide a more comprehensive and meaningful assessment of CDI performance. For example, CDI programs can track CMI changes for specific DRGs, clinical conditions, or service lines that are targeted for documentation improvement initiatives. This can help identify the impact of CDI interventions on documentation quality, accuracy, and completeness.
* A. Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI. This is not the best way to measure CMI as a metric of CDI performance, because it may not reflect the true complexity and severity of the patients treated at the facility. Focusing only on high RW procedures may overlook other documentation improvement opportunities for lower RW procedures or medical cases that may also affect patient outcomes, quality indicators, and reimbursement.
* C. Month-to-month and focus on patient volumes to determine the raise the overall CMI. This is not a valid way to measure CMI as a metric of CDI performance, because patient volumes do not directly affect CMI. CMI is calculated by dividing the total relative weights by the total number of discharges, so increasing patient volumes will not necessarily raise the overall CMI unless the relative weights also increase.
* D. Month-to-month to show CMI variability as a barometer of a specific month. This is not a reliable way to measure CMI as a metric of CDI performance, because month-to-month variations in CMI may be due to random fluctuations or seasonal effects that are not related to CDI efforts. Measuring CMI over a longer period of time can provide a more stable and accurate picture of CDI performance.
References:
✑ CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
✑ Case Mix Index (CMI) | Definitive Healthcare
✑ Q&A: Understanding case mix index | ACDIS

A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is

1. A. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admissio
2. B. Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment.
3. C. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.
4. D. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admissio
5. E. Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other.
6. F. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admissio
7. G. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.

Correct Answer: C
According to the AHIMA/ACDIS Query Practice Brief, a compliant query should provide multiple choice answer options that are supported by clinical indicators and include a non- leading query statement1. Option C meets these criteria, as it provides a list of possible diagnoses that are relevant to the patient??s condition and asks the provider to indicate which one they are treating. Option C also does not imply or suggest a preferred answer or outcome, and allows the provider to choose unable to determine or other if none of the listed options apply. Option A is not compliant, as it does not provide any answer options and implies that the provider should order more tests to capture a higher severity of illness. Option B is not compliant, as it provides only one answer option and suggests that the provider should document it based on the clinical indicators. Option D is not compliant, as it provides only one answer option and implies that the provider should document it based on the indications. References:
✑ Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?

1. A. Recommend the physicians to be involved in the project
2. B. Bring together a team of physicians and informatics specialists
3. C. Alert senior leadership to the record documentation problem
4. D. Gather data on the incidence of inaccurate record documentation

Correct Answer: D
The first step the CDI director should take is to gather data on the incidence of inaccurate record documentation because it is important to establish the baseline and scope of the problem, as well as to identify the potential causes and consequences of over-using electronic copy and paste. Data collection can help to measure the frequency, severity, and impact of documentation errors, such as inconsistencies, redundancies, contradictions, or omissions. Data collection can also help to determine the best methods and tools for conducting the documentation integrity project, such as audits, surveys, interviews, or software applications. (CDIP Exam Preparation Guide1)
References:
✑ CDIP Exam Content Outline2
✑ CDIP Exam Preparation Guide1

Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?

1. A. Reporting and the use of technology
2. B. Value and mission statements
3. C. Benchmarks and case mix index
4. D. Diagnostic related groups and revenue cycle

Correct Answer: B
A CDI program??s vision should reflect its purpose, values, and goals, and align with the organization??s overall vision and mission. Value and mission statements help define the CDI program??s role, scope, and objectives, and communicate them to stakeholders. Reporting and the use of technology are important tools for a CDI program, but they are not part of its vision. Benchmarks and case mix index are performance indicators that measure the CDI program??s outcomes, but they do not reflect its vision. Diagnostic related groups and revenue cycle are aspects of reimbursement that may be affected by the CDI program, but they are not the primary focus of its vision.