CDI Question and Answer Key, Questions & Answers, 100% Accurate.

CDI Question and Answer Key, Questions & Answers, 100% Accurate. What is a reason a physician documentation can be difficult to review? - ✔✔-Illegible handwriting The best scientific data available for clinical docum ...

CDI Question and Answer Key, Questions & Answers, 100% Accurate. What is a reason a physician documentation can be difficult to review? - ✔✔-Illegible handwriting The best scientific data available for clinical documentation is also known as - ✔✔-Evidence-based medicine The two-part theory for high-quality clinical documentation is a cause-and-effect theory that is derived from which two sources? - ✔✔-Legal/Regulatory Sources and Peer-Reviewed Research When discussing completeness in a health record, the physician has fully addressed all concerns, as well as what other authentication? - ✔✔-Signature and date Peer-reviewed academic literature states that this factor shows a relationship to quality of care as well as support for concurrent CDI programs: - ✔✔-Documentation What evidence supports the lack of high-quality clinical documentation in the medical field? - ✔✔-CDI is not taught in medical school Which item is not recommended by the HHS and the OIG for minimum compliance with clinical documentation regulations? - ✔✔-Physicians should include vaccination records What does "reliable" in high-quality clinical documentation mean? - ✔✔-Physician documentation supports medical treatment Which item is an important aspect of consistent high-quality clinical documentation? - ✔✔-Creates a clear picture for subsequent reviewers of documentation Which aspect of the discharge summary is the biggest challenge to house staff, mid-level practitioners, and attending physicians as they compose the patient's discharge summary? - ✔✔-Timeliness Which aspect of the patient's health record can a member of the house staff or midlevel practitioner create, yet ultimately needs the attending physician to confirm accuracy? - ✔✔-Problem list Interns, residents, and fellows are physicians with lesser accountability due to their inability to act as an attending physician and are also known as ______. - ✔✔-House staff Which two medical professionals serve as mid-level practitioners by supporting physicians in the delivery of care? - ✔✔-Nurse practitioners and physician assistants In 1982, which aspect of medical billing/reimbursement increased the demand for accuracy and timeliness with regard to medical coding? - ✔✔-Reimbursement was driven by codes assigned to patient care Which hands-on provider's documentation should the coder not use for final coding? - ✔✔-Diagnostic radiologist Which practitioners, along with coding professionals, are proficient at picking up deficiencies in clinical documentation yet must focus on giving care? - ✔✔-Nurses Which healthcare setting requires high levels of proactivity from management and clinical teams to ensure accurate and timely clinical documentation? - ✔✔-Outpatient Which item is not an inpatient healthcare setting? - ✔✔-Emergency department High-quality clinical documentation is the basis for what standard? - ✔✔-Gold standard What allows the diagnostic, treatment, and response of information of the patient to be aggregated into a uniform data set? - ✔✔-Coding What part of the health record, usually located at the end the document, provides a complete picture of the patient's diagnosis? - ✔✔-Impression and plan What description is an aspect of the coding professionals' job? - ✔✔-Asking the physician about any gaps in documentation that may represent an insufficiently documented diagnosis What has been called the equalizer for prospective inpatient reimbursement? - ✔✔-Severity-based DRG What is the ultimate goal of the installation of the POA indicator? - ✔✔-To consider severity, resource utilization, and quality indicators in reimbursement Within how many hours of discharge does the attending physician normally provide the discharge summary to the coding department? - ✔✔-24-48 Which form of documentation is the essence of the health record on which the coder relies? - ✔✔- Progress notes A query is necessary when a conflict in documentation exists between an attending physician and which practitioner? - ✔✔-Anesthesiologist What does the fifth digit "1" represent with regard to the myocardial infarction code? - ✔✔-Current admission What is suggested as a requirement for reflection of current medical practices and supports worldwide epidemiology? - ✔✔-New coding system A 3M study suggested that the reimbursement impact on the implementation of ICD-10-CM/PCS would be what? - ✔✔-Minimal What is the estimated negative impact of the top 25 MS-DRGs mentioned in the text? - ✔✔-1.4 percent What is the first step required to determine the facility specific impact of ICD-10 implementation? - ✔✔- Begin dual coding What is the principal tool used by CDI programs to enhance efficiency? - ✔✔-Analytics What should the facilities interested in investing in a CDI program perform on data and documentation? - ✔✔-Objective analysis When analyzing coding data, what system has one of the highest levels of aggregation? - ✔✔-DRG Which reimbursement method allows for multiple assignments for each encounter and allows for the analysis of clinical documentation to remain on the coding level? - ✔✔-APC During the review of clinical documentation, on what is it imperative to focus the review? - ✔✔-Current provider documentation Review of inconsistencies or patterns that do not meet DRG target norms, allows this data to be used for what purpose? - ✔✔-Clinical documentation Assessmen