Certified Documentation Integrity Practitioner (CDIP)

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A patient admitted with sepsis develops acute kidney injury during the stay, which the hospitalist documents but does not explicitly link to the sepsis. Clarifying this causal relationship through a physician query would most likely result in:

No impact on APR-DRG assignment since sepsis already carries high severity A reduction in the SOI subclass by adding a competing diagnosis An impact only on outpatient reimbursement, not inpatient APR-DRG grouping An increase in both SOI and ROM subclasses, more accurately reflecting the patient's clinical complexity

Correct Answer:

An increase in both SOI and ROM subclasses, more accurately reflecting the patient's clinical complexity

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