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At discharge, the physician documents, "Possible gram-negative pneumonia." No later documentation rules out the condition. How should the diagnosis generally be handled for an inpatient admission?
Correct Answer: A 🗳️
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A patient's baseline serum creatinine is 0.9 mg/dL. Forty-eight hours after admission, the creatinine is 1.5 mg
/dL. Urine output has also decreased. Which condition is most appropriate for the CDI specialist to consider as a clarification opportunity?
Correct Answer: D 🗳️
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A patient is admitted with right-sided weakness and aphasia. MRI confirms an acute left cerebral infarction.
Two days later, aphasia resolves but right-sided weakness remains. The physician's documentation continues to state "TIA." What should the CDI specialist do?
Correct Answer: C 🗳️
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A patient with sepsis has acute confusion, impaired attention, fluctuating mental status, and no focal neurologic findings. CT of the head is negative. The provider documents only "AMS secondary to infection." Which clarification would be MOST clinically appropriate?
Correct Answer: A 🗳️
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Which pressure-ulcer category is specifically included in the traditional CMS HAC payment policy when the condition is not present on admission?
Correct Answer: A 🗳️
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