Certified Documentation Improvement Practitioner (CDIP) — Question 22

A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0°. On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to:

Answer options

• A. code pneumonia, unspecified
• B. query the provider to see if pseudomonas sepsis is supported by the health record
• C. code pseudomonas pneumonia
• D. query the provider to document the etiology of pneumonia

Correct answer: D

Explanation

The correct answer is D because it is important to clarify the cause of pneumonia for accurate coding and treatment. Options A and C do not provide the necessary specificity regarding the patient's condition, while option B may not be relevant since the focus should be on documenting the pneumonia's etiology rather than checking for sepsis.