CDIP: Domain 3 - Rec Review & Document Clarification

Online Education Courses

This four-lesson course covers the process of reviewing the record and seeking document clarification through compliant queries. Pertinent quality measures will be discussed, as well as the process to resolve differences between a working DRG and a final DRG.


At the end of this course, students will be able to:

  • Identify the components of compliant query writing.
  • Determine documentation requirements for query writing.
  • Determine the necessary clinical indicators to support the query.
  • Identify the specificity, diagnosis clarification and abnormal findings utilized for an effective query.
  • Identify the stakeholders in a CDI program.
  • Identify HACs, PSI, and Core measure and how a CDI program utilizes these quality measures.
  • Recognize that communication in a CDI program can be electronic or handwritten.
  • Summarize the importance of query follow-up.
  • Assess the importance of queries for clarification of documentation for MS-DRGs, APR-DRGs.
  • Define missed opportunities.
  • Review the importance of education for providers.
  • Explain the importance of the response rate.
  • Clarify how to document the query follow-up.
  • Evaluate the process of having policies and procedures for a CDI program.
  • Explain how to resolve differences between a Working DRG versus Final DRG.



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