A physician is completing rounds when a CDI specialist identifies conflicting documentation that can be clarified immediately. Which approach is MOST appropriate?

• A. Tell the physician which diagnosis produces the correct MS-DRG
• B. Avoid verbal discussion because all queries must be electronic
• C. Wait until final billing because concurrent clarification is inappropriate
• D. Discuss the issue professionally with the physician and ensure the clarification process meets organizational query documentation requirements

A patient with an indwelling central venous catheter develops fever and positive blood cultures for Staphylococcus aureus. The physician documents "bacteremia" but does not establish whether the catheter caused the infection. Which action is MOST appropriate?

• A. Code sepsis because the blood culture is positive
• B. Assume the catheter is unrelated because bacteremia was documented first
• C. Automatically code a central-line infection
• D. Query the provider regarding the relationship between the catheter and infection

The progress note on hospital day 2 of a patient's admission states that the patient got up from the bed to go to the bathroom just after housekeeping had mopped the floor. The patient slipped and fell onto the floor, sustaining a broken wrist. The diagnosis of a fractured wrist will:

• A. Be coded and assigned a POA of "U"
• B. Be considered a CC for calculation of the final MS-DRG
• C. Not be coded because it is a hospital-acquired condition
• D. Not be recognized as a CC because it was a hospital-acquired condition

A patient's baseline creatinine is 1.0 mg/dL. Following prolonged hypotension, creatinine rises to 3.8 mg/dL.
Urinalysis demonstrates granular casts, and the nephrologist documents "acute renal failure" but does not specify the underlying renal lesion. Which condition would be MOST appropriate to consider in a clinically supported clarification query?

• A. Pyelonephritis
• B. Chronic kidney disease stage 5
• C. Acute tubular necrosis
• D. Nephrotic syndrome

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?

• A. Code both diagnoses without clarification
• B. Query the provider regarding cerebral infarction versus TIA based on the imaging and persistent deficit
• C. Accept TIA because it was documented first
• D. Change TIA to cerebral infarction independently