A 70-year-old severely malnourished nursing home patient is admitted for a pressure ulcer covered by eschar on the right hip. The provider is queried to clarify the stage of the pressure ulcer. Because the wound has not been debrided, the provider responds “unable to determine”. How will the stage of this pressure ulcer be coded?
When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?
In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?
The provider was queried because the patient met clinical criteria for acute hypoxic respiratory failure. The response to the query was different than what was expected by the clinical documentation integrity practitioner (CDIP). What should the CDIP do?
Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?
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?
