2025 Realistic Verified Free AHIMA CDIP Exam Questions
CDIP Real Exam Questions and Answers FREE
NEW QUESTION # 43
A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate time frame. What should the CDIP do next?
- A. Escalate issue to hospital administration
- B. Escalate issue to medical staff leadership
- C. Query wound care nurse
- D. Query surgical consultant
Answer: B
Explanation:
Explanation
According to the AHIMA-ACDIS Practice Brief, a query escalation policy should describe how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, the department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for the organization1. In this case, since the attending physician has not responded to the query in an appropriate time frame, the CDIP should escalate the issue to the medical staff leadership, such as the chief medical officer, the department chair, or the physician advisor, who can facilitate communication and education with the attending physician and ensure documentation integrity and compliance1.
References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1
NEW QUESTION # 44
Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program?
- A. Adjusted case mix index
- B. Program for evaluating payment patterns electronic report
- C. Present on admission indicators
- D. Hospital acquired conditions
Answer: A
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, the adjusted case mix index (CMI) is a measure that demonstrates the relative severity and complexity of patients treated in a hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program1. The adjusted CMI is calculated by multiplying the unadjusted CMI by a factor that accounts for the percentage of Medicare patients in the hospital2. The higher the adjusted CMI, the higher the expected reimbursement per patient, and the more effective the CDI program is assumed to be3. The other options are not correct because they do not measure the severity and complexity of patients or the financial impact of CDI. Hospital acquired conditions (HACs) are conditions that are not present on admission and are considered preventable by CMS, and may result in reduced reimbursement or penalties4. The program for evaluating payment patterns electronic report (PEPPER) is a report that provides hospital-specific data on potential overpayments or underpayments for certain services or diagnoses, and helps identify areas of risk or opportunity for improvement. Present on admission (POA) indicators are codes that indicate whether a condition was present at the time of admission or acquired during the hospital stay, and affect the assignment of DRGs and HACs. References:
CDIP Exam Preparation Guide - AHIMA
Demystifying and communicating case-mix index - ACDIS
What is Case Mix Index? | The Importance of CMI
Hospital-Acquired Conditions (HACs) | CMS
[PEPPER Resources]
[Present on Admission Reporting Guidelines - CMS]
NEW QUESTION # 45
A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate
- A. subsequent
- B. initial
- C. sequela
- D. aftercare
Answer: D
Explanation:
Explanation
The ICD-10-CM 7th character code value should indicate aftercare for a patient who falls off a ladder and undergoes a right femur procedure, and then returns to the hospital for removal of the external fixation device.
Aftercare codes are used to capture encounters for follow-up care after completed treatment of an injury or condition, such as removal of external fixation devices, casts, or pins. Aftercare codes are not used for subsequent encounters for complications or infections related to the injury or condition5 References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 5:
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 46
A query should include
- A. the impact of reimbursement
- B. information from previous encounters
- C. the impact on quality
- D. relevant clinical indicators
Answer: D
Explanation:
Explanation
A query should include relevant clinical indicators from the health record that support the need for clarification and the query options. Clinical indicators are objective and measurable signs, symptoms, laboratory results, diagnostic test results, medications, treatments, and other documented findings that are related to a specific diagnosis or condition. Information from previous encounters, the impact on quality, and the impact of reimbursement are not appropriate to include in a query, as they may introduce bias, lead the provider, or imply a desired response.
NEW QUESTION # 47
A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition. Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?
- A. 61105 Twist drill hole subdural/ventricular puncture
- B. 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion
- C. 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma
- D. 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
Answer: D
Explanation:
Explanation
According to the CPT code description, 61154 is the appropriate code for a burr hole procedure for evacuation of a subdural hematoma. A burr hole is a small hole made in the skull with a surgical drill to access the brain or its coverings2. A subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, which are two of the three layers that cover the brain3. The evacuation of the hematoma involves removing the clot and relieving the pressure on the brain. The other codes are not applicable for this procedure because they describe different methods of access (twist drill hole) or different purposes (biopsy or puncture)4.
References:
CDI Week 2020 Q&A: CDI and key performance indicators1
Mayo Clinic: Burr hole2
MedlinePlus: Subdural hematoma3
CPT Code Book 20234
NEW QUESTION # 48
In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?
- A. Emphasize the Medicare requirements for documentation
- B. Examples from the hospital's actual cases
- C. The latest Medicare Provider and Analysis Review data
- D. Explanations on how severity of illness and risk of mortality impact reimbursement
Answer: B
Explanation:
Explanation
In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, examples from the hospital's actual cases are the most effective for physicians in a hospital. Examples from the hospital's actual cases can show how specific documentation elements, such as diagnoses, procedures, complications, comorbidities, and present on admission indicators, can affect the severity of illness and risk of mortality scores of the patients, as well as the hospital's performance and reputation. Examples from the hospital's actual cases can also provide feedback and education to the physicians on how to improve their documentation practices and standards. References: :
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf :
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 49
The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?
- A. Have CDI manager teaming with coding supervisor to monitor physician responses
- B. Allow physician to respond via e-mail
- C. Require physicians to document responses in charts
- D. Permit CDI practitioners to document physician responses in the charts
Answer: C
Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, one of the best practices for a compliant query process is to require physicians to document their responses to queries in the health record1. This ensures that the documentation is consistent, accurate, and complete, and that the query and response are part of the permanent record. Verbal responses are not acceptable, as they do not provide a clear audit trail and may lead to errors or discrepancies in coding and billing1. Therefore, the CDI manager should educate the physicians on the importance of documenting their responses in the charts and monitor their compliance. The other options are not recommended, as they may compromise the integrity of the documentation or violate the query guidelines1. References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
NEW QUESTION # 50
The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA's Guidelines for Achieving a Compliant Query Practice?
- A. Complete the documentation at the time of discussion or immediately following
- B. Complete the documentation when there is a provider agreement
- C. Complete the documentation immediately after the provider's response
- D. Complete the documentation at the end of the day when entering cases reviewed
Answer: A
Explanation:
Explanation
According to AHIMA's Guidelines for Achieving a Compliant Query Practice, the clinical documentation integrity practitioner (CDIP) should complete the documentation at the time of discussion or immediately following to avoid a compliance risk for this follow up failure. This is because verbal queries are considered part of the health record and must be documented in a timely and accurate manner to reflect the provider's response and any changes in documentation or coding. Completing the documentation later or only when there is an agreement may result in errors, omissions, inconsistencies, or delays that may affect the quality and integrity of the health record and the query process. (AHIMA Guidelines for Achieving a Compliant Query Practice1) References:
AHIMA Guidelines for Achieving a Compliant Query Practice1
NEW QUESTION # 51
While reviewing a chart, a clinical documentation integrity practitioner (CDIP) needs to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes
1 and 2. Which coding reference should be used?
- A. AHA Coding Clinic for ICD-10-CM
- B. AMA CPT Assistant
- C. Faye Brown's Coding Handbook
- D. ICD-10-CM Official Guidelines for Coding and Reporting
Answer: D
Explanation:
Explanation
The coding reference that should be used to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes 1 and 2 is the ICD-10-CM Official Guidelines for Coding and Reporting. This document provides the conventions and instructions for the proper use of the ICD-10-CM classification system, including the definitions and examples of the Includes Notes and Excludes Notes 1 and 2. The document is updated annually by the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), and is available online at 2. The other coding references listed are not specific to ICD-10-CM or do not contain the general rules for the Includes Notes and Excludes Notes 1 and 2.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 4
NEW QUESTION # 52
A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?
- A. Query for a diagnosis associated with the dietician's finding of malnutrition
- B. Query if the malignant pleural effusion is the reason for admission
- C. Query for protein calorie malnutrition
- D. Query for malignant pleural effusion
Answer: D
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement2. In this case, the patient has a large right lung pleural effusion related to lung cancer stage II, which is documented multiple times. However, the documentation does not specify whether the pleural effusion is malignant or not. A malignant pleural effusion is a condition where cancer cells spread to the pleural space and cause fluid accumulation3. A malignant pleural effusion is a major complication or comorbidity (MCC) that affects the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality scores of the hospital4. Therefore, a post discharge query opportunity should be sent to the physician to clarify whether the pleural effusion is malignant or not, based on the clinical indicators such as chest x-ray, thoracentesis, and fluid analysis. The query should provide answer options such as malignant pleural effusion, non-malignant pleural effusion, unable to determine, or other. The other options are not correct because they either do not affect the SOI/ROM of the patient (A and C), or they do not address the specificity of the diagnosis (D). References:
CDIP Exam Preparation Guide - AHIMA
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Malignant Pleural Effusion: Symptoms, Causes, Diagnosis & Treatment Q&A: Coding for malignant pleural effusions | ACDIS
NEW QUESTION # 53
Which of the following committees should determine the chain of comnfand that will be used to manage physicians who are either unresponsive or uncooperative with the clinical documentation integrity (CDI) program?
- A. Oversight
- B. Operations
- C. Communications
- D. Compliance
Answer: A
Explanation:
Explanation
The oversight committee is responsible for establishing the policies, procedures, and guidelines for the CDI program, as well as monitoring its performance and outcomes. The oversight committee should include representatives from senior leadership, medical staff, coding, quality, compliance, and other relevant stakeholders. The oversight committee should determine the chain of command that will be used to manage physicians who are either unresponsive or uncooperative with the CDI program, as well as the consequences for non-compliance. The other committees are not directly involved in setting the chain of command or the disciplinary actions for the CDI program. The communications committee is responsible for facilitating the information flow and feedback among the CDI staff, providers, coders, and other departments. The operations committee is responsible for managing the day-to-day activities and functions of the CDI staff, such as staffing, training, productivity, and workflow. The compliance committee is responsible for ensuring that the CDI program adheres to the ethical and legal standards and regulations, such as query compliance, documentation integrity, and privacy and security.
NEW QUESTION # 54
A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?
- A. No query is needed
- B. Bring this case up in weekly Health Information Management meetings for further action
- C. Take the case to physician advisor/champion to discuss further action
- D. Query physician for POA
Answer: D
Explanation:
Explanation
A query should be generated to ask the physician for the POA indicator of the fall because the documentation is unclear whether the fall was present at the time of inpatient admission or not. The POA indicator is used to identify conditions that are present or not present at the time of admission, and has payment implications for certain hospital-acquired conditions (HACs). According to CMS, a fall resulting in trauma is one of the HACs that will not be paid at a higher rate if it is not present on admission. Therefore, it is important to clarify the POA indicator of the fall to ensure accurate coding and reimbursement. A query should be non-leading, concise, clear, relevant, and consistent with CDI standards and guidelines.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) Coding | CMS1 Present on Admission Indicators - Novitas Solutions2
NEW QUESTION # 55
The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is
- A. 05HM33Z Insertion of infusion device into right internal jugular vein, percutaneous approach
- B. 02H633Z Insertion of infusion device into right atrium, percutaneous approach
- C. 05HP33Z Insertion of infusion device into right external jugular vein, percutaneous approach
- D. 02HV33Z Insertion of infusion device into superior vena cava, percutaneous approach
Answer: A
Explanation:
Explanation
According to the ICD-10-PCS Reference Manual 2023, the insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is coded as follows1:
The first character 0 indicates the Medical and Surgical section.
The second character 5 indicates the Extracorporeal or Systemic Assistance and Performance root operation, which is defined as "Putting in or on a device that completely takes over a body function by extracorporeal means"1.
The third character H indicates the Central Vein body system, which includes the internal jugular vein1.
The fourth character M indicates the Infusion Device device value, which is defined as "A device that is inserted into a body part to deliver fluids or other substances to a body part or into the circulation"1.
The fifth character 3 indicates the Right Internal Jugular Vein body part value, which is the specific site of the procedure1.
The sixth character 3 indicates the Percutaneous approach, which is defined as "Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure"1.
The seventh character Z indicates No Qualifier, which means there is no additional information necessary to complete the code1.
Therefore, the correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is 05HM33Z.
References:
ICD-10-PCS Reference Manual 20231
NEW QUESTION # 56
The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the
- A. Health Information Management coding staff
- B. organization's medical and surgical staff
- C. organization senior administration staff
- D. clinical documentation integrity staff
Answer: B
Explanation:
Explanation
The physician advisor/champion is a key role in the CDI program who serves as a liaison between the CDI staff and the organization's medical and surgical staff. The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the organization's medical and surgical staff to promote awareness, understanding, and compliance with CDI initiatives and goals.
References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 97-98.
NEW QUESTION # 57
A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician's documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit. Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD.
Discharge diagnoses:
1. Pneumonia
2. COPD
3. Current smoker
What is the correct diagnostic related group assignment?
- A. DRG 202 Bronchitis and Asthma with CC/MCC
- B. DRG 190 Chronic Obstructive Pulmonary Disease with MCC
- C. DRG 194 Simple Pneumonia and Pleurisy without CC/MCC
- D. DRG 204 Respiratory Signs and Symptoms
Answer: B
Explanation:
Explanation
According to the ICD-10-CM/PCS MS-DRG Definitions Manual, DRG 190 is assigned for patients with a principal diagnosis of chronic obstructive pulmonary disease (COPD) and a major complication or comorbidity (MCC)1. Pneumonia is considered an MCC for this DRG2. Therefore, the patient in this case meets the criteria for DRG 190. The other options are incorrect because they do not match the principal diagnosis or the MCC of the patient.
ICD-10-CM/PCS MS-DRG Definitions Manual
ICD-10-CM/PCS MS-DRG v38.0 Definitions Manual - MDC 4: Diseases and Disorders of the Respiratory System
NEW QUESTION # 58
The BEST place for the provider to document a query response is which of the following?
- A. The next progress note and the problem list
- B. An addendum to the history and physical
- C. The next progress note and all subsequent notes including the discharge summary
- D. The query form
Answer: A
Explanation:
Explanation
The best place for the provider to document a query response is the next progress note and the problem list because this ensures that the query response is timely, consistent, and integrated into the health record. According to the AHIMA/ACDIS query practice brief1, the provider should document the query response in the health record as soon as possible after receiving the query, preferably in the next progress note.
The provider should also update the problem list to reflect any new or revised diagnoses resulting from the query response. This helps to maintain an accurate and comprehensive list of the patient's current and chronic conditions, which can facilitate continuity of care, quality reporting, and reimbursement. Documenting the query response in an addendum to the history and physical or only on the query form is not sufficient, as it may not capture the current status of the patient or be easily accessible to other providers or coders.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) Guidelines for Achieving a Compliant Query Practice-2022 Update1
NEW QUESTION # 59
Creating policies and procedures for the query process will help eliminate
- A. duplication
- B. indecision
- C. confusion
- D. risk
Answer: C
Explanation:
Explanation
Creating policies and procedures for the query process will help eliminate confusion among CDI staff, providers, coders, and other stakeholders regarding the purpose, scope, format, and expectations of the query process. Policies and procedures should be based on industry standards and best practices, and should be reviewed and updated regularly.
References: AHIMA/ACDIS. "Guidelines for Achieving a Compliant Query Practice (2019 Update)." Journal of AHIMA 90, no. 2 (February 2019): 20-29.
NEW QUESTION # 60
When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?
- A. Surgical
- B. Admitting
- C. Credentialing
- D. Consulting
Answer: B
Explanation:
Explanation
When queries are part of the health record, which is recommended by AHIMA and ACDIS, physicians are responsible for responding to queries in a timely manner and ensuring that their documentation is complete and accurate. If a provider receives too many deficiencies due to incomplete records for failure to respond to queries, their admitting privilege could be suspended by the medical staff committee as a disciplinary action.
References: AHIMA/ACDIS. "Guidelines for Achieving a Compliant Query Practice (2019 Update)." Journal of AHIMA 90, no. 2 (February 2019): 20-29.
NEW QUESTION # 61
A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?
- A. Bring together a team of physicians and informatics specialists
- B. Recommend the physicians to be involved in the project
- C. Gather data on the incidence of inaccurate record documentation
- D. Alert senior leadership to the record documentation problem
Answer: C
Explanation:
Explanation
The first step the CDI director should take is to gather data on the incidence of inaccurate record documentation because it is important to establish the baseline and scope of the problem, as well as to identify the potential causes and consequences of over-using electronic copy and paste. Data collection can help to measure the frequency, severity, and impact of documentation errors, such as inconsistencies, redundancies, contradictions, or omissions. Data collection can also help to determine the best methods and tools for conducting the documentation integrity project, such as audits, surveys, interviews, or software applications. (CDIP Exam Preparation Guide1) References:
CDIP Exam Content Outline2
CDIP Exam Preparation Guide1
NEW QUESTION # 62
A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is
- A. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other. - B. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment. - C. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.
- D. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.
Answer: A
Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, a compliant query should provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement1. Option C meets these criteria, as it provides a list of possible diagnoses that are relevant to the patient's condition and asks the provider to indicate which one they are treating. Option C also does not imply or suggest a preferred answer or outcome, and allows the provider to choose unable to determine or other if none of the listed options apply. Option A is not compliant, as it does not provide any answer options and implies that the provider should order more tests to capture a higher severity of illness. Option B is not compliant, as it provides only one answer option and suggests that the provider should document it based on the clinical indicators. Option D is not compliant, as it provides only one answer option and implies that the provider should document it based on the indications. References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
NEW QUESTION # 63
The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate.
What might this indicate to the CDI manager?
- A. CDI staff need education on identifying query opportunities
- B. The program is successful because documentation has improved
- C. The decrease in hospital census has caused a lack of query opportunities
- D. The loss of a large volume of patients has impacted workflow
Answer: A
Explanation:
Explanation
A drastic drop in the physician query rate might indicate to the CDI manager that the CDI staff need education on identifying query opportunities. The physician query rate is a metric that measures the percentage of records that have at least one query sent by the CDI staff to clarify or improve the documentation. A high query rate may reflect a high level of documentation quality issues or a high level of CDI staff vigilance and expertise. A low query rate may reflect a low level of documentation quality issues or a low level of CDI staff awareness and competence 2. Therefore, a drastic drop in the query rate could suggest that the CDI staff are missing some query opportunities or are not following the query policies and procedures. The CDI manager should investigate the reasons for the drop and provide education and feedback to the CDI staff on how to identify and address query opportunities effectively and compliantly 3.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: Understanding CDI Metrics - AHIMA 2 3: The Natural History of CDI Programs: A Metric-Based Model 5
NEW QUESTION # 64
Which of the following is an appropriate first step to address physicians with low query response rates?
- A. A meeting between the physician advisor/champion and the noncompliant physician
- B. An educational session between the clinical documentation integrity practitioner (CDIP) and physician
- C. The physician receives a suspension until query responses are improved
- D. The medical staff review the physician's noncompliance to consider sanctions
Answer: B
Explanation:
Explanation
An appropriate first step to address physicians with low query response rates is an educational session between the clinical documentation integrity practitioner (CDIP) and physician because it provides an opportunity to explain the purpose and benefits of the query process, to identify and address any barriers or challenges to responding, and to offer feedback and guidance on how to improve query response rates. An educational session can also help to build rapport and trust between the CDIP and the physician, and to demonstrate respect and professionalism. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Understanding CDI Metrics3
NEW QUESTION # 65
A noncompliant query includes querying the provider regarding
- A. morbid obesity due to BMI of 40.9 documented on the history and physical
- B. sepsis that was present on admission because sepsis was only documented in the discharge summary
- C. acute blood loss anemia due to low hemoglobin treated with iron supplements
- D. gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators
Answer: D
Explanation:
Explanation
A noncompliant query includes querying the provider regarding gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators because it may lead to over-specification of a diagnosis that is not supported by the health record. A compliant query should be based on the clinical evidence and documentation in the record, and should not suggest or imply a diagnosis that is not clinically relevant or plausible. A query should also not be driven by reimbursement or coding factors, but by the need to improve the quality and accuracy of documentation. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Guidelines for Achieving a Compliant Query Practice (2019 Update)3
NEW QUESTION # 66
Which of the following is considered a hospital-acquired condition if not present on admission?
- A. Diabetes with hypoglycemia
- B. Air leak
- C. Blood incompatibility
- D. Stage I and II pressure ulcers
Answer: C
Explanation:
Explanation
Blood incompatibility is considered a hospital-acquired condition if not present on admission, according to the CMS Hospital-Acquired Conditions (HAC) Reduction Program. This program reduces payments to hospitals that have high rates of certain conditions that are acquired during the hospital stay and could have been prevented by following evidence-based guidelines. Blood incompatibility is one of the 14 HAC categories that are included in the program, and it refers to a patient receiving a blood transfusion with incompatible blood type or Rh factor, which can cause serious adverse reactions such as hemolysis, anemia, renal failure, or death 23. Blood incompatibility is a preventable condition that can be avoided by proper blood typing and cross-matching before transfusion, and by following strict protocols and procedures for blood handling and administration 4.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 5 2: Hospital-Acquired Conditions | CMS 1 3: Hospital Acquired Conditions (HACs) - New York State Department of Health 3 4: Transfusion Reactions - Hematology and Oncology - Merck Manuals Professional Edition 6
NEW QUESTION # 67
A modifier may be used in CPT and/or HCPCS codes to indicate
- A. a service or procedure resulted in expected outcomes
- B. a service or procedure was increased or reduced
- C. a service or procedure was performed in its entirety
- D. a service or procedure was performed by one provider
Answer: B
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a modifier is a two-digit numeric or alphanumeric code that may be used in CPT and/or HCPCS codes to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code1. One of the reasons to use a modifier is to indicate that a service or procedure was increased or reduced in comparison to the usual service or procedure2. For example, modifier 22 can be used to report increased procedural services that require substantially greater time, effort, or complexity than the typical service3. The other options are not correct because they do not reflect the purpose of using modifiers. A service or procedure performed in its entirety does not need a modifier, as it is assumed to be the standard service or procedure. A service or procedure resulting in expected outcomes does not affect the coding or reimbursement of the service or procedure. A service or procedure performed by one provider may need a modifier depending on the type of provider, the place of service, and the payer rules, but it is not a general reason to use a modifier. References:
CDIP Exam Preparation Guide - AHIMA
Modifiers: A Guide for Health Care Professionals - CMS
CPT Modifiers: 22 Increased Procedural Services | AAPC
NEW QUESTION # 68
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