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A patient was admitted with complaints of confusion, weakness, and slurred speech. A CT of the head and MRI were performed and resulted in normal findings. Daily aspirin was administered and a speech therapy evaluation was conducted. The final diagnosis on discharge was transient ischemic attack, and cerebrovascular disease was ruled out. What is the correct diagnostic related group assignment?

• A. 066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC
• B. 069 Transient Ischemia
• C. 093 Other Disorders of Nervous System without CC/MCC
• D. 948 Signs and Symptoms without MCC

A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for psuedomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would

• A. not increase relative weight
• B. increase relative weight
• C. not meet medical necessity
• D. meet medical necessity

Several physicians at a local hospital are having difficulty providing adequate documentation on patients admitted with a diagnosis of pneumonia with or without clinical indications of gram-negative pneumonia. Subsequently, clinical documentation integrity practitioners (CDIPs) are altering health records. Which policy and procedure should be developed to ensure compliant practice?

• A. Quality improvement standards
• B. Performance standards
• C. Accreditation standards
• D. Professional ethical standards

A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

• A. Query the physician to clarify if patient has acute COPD exacerbation.
• B. Query the physician to clarify for type of COPD such as severe asthma.
• C. Query the physician to clarify if CXR result means patient has pneumonia.
• D. Query the physician to clarify for clinical significance of the CXR results.

A hospital is conducting a documentation integrity project for the purpose of reducing indiscriminate use of electronic copy and paste of patient information in records by physicians. Which data should be used to quantify the extent of the problem?

• A. Results of a survey of physicians that asks about documentation practices
• B. Number of coder queries regarding inconsistent physician record documentation
• C. Incidence of redundancies in physician notes in a sample of hospital admissions
• D. Percent of insurance billings denied due to lack of record documentation