Clinical Documentation Improvement (CDI)

Clinical Documentation Improvement (CDI) Assignment

Part 3 – Your facility received an initial DRG validation denial letter from the RAC. The case scenario includes a 75-year-old patient admitted through the Emergency Department for renal failure and COPD exacerbation. The reason for admission is COPD exacerbation. The physician also documented protein-calorie deficiency malnutrition in the discharge summary. The Clinical Documentation Specialist notices that the physician’s supporting documentation is missing, including whether this condition was present of admission.

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Task 1: Realizing that you will need to add Querying to your process list, clearly identify the intent of queries included in a procedure format and provide examples of why a provider might receive a query.

Task 2: It is time to address the case at hand.

The RAC suggests that the patient did not have protein-calorie deficiency malnutrition.

Identify a scholarly article on protein-calorie deficiency malnutrition (i.e. Google Scholar or other scholarly resources http://scholar.google.com/); then write a query to the physician to address the MS DRG for principle diagnosis of COPD exacerbation with protein- calorie deficiency malnutrition.

You may add additional detail to the case such as medications, treatments, and such to support query development. *Remember, you do not want to make your query leading!