(Completed) AHIMA Certified Documentation Integrity Practitioner (CDIP) Exam

Description

AHIMA Certified Documentation Integrity Practitioner (CDIP) Exam

Question

Which of the following is an optimal way to communicate between the CDIP and the rest of the healthcare team to facilitate accurate documentation?

A. Informally discuss all assigned cases with the CEO.

B. Make daily verbal or phone contact as needed with nurses working with MCC.

<u>C. Attend scheduled electronic medical record (EMR) meetings with MCC.</u>

D. Maintain CDI provider education by posting flyers regarding MCC.

Question

A patient is admitted as an inpatient for a myocardial infarction and falls out of bed, requiring a hip replacement. Which MS-DRG would this fall under?

A. Myocardial infarction discharged alive with CC

<u>B. Major hip and knee joint replacement or attachment of lower extremity with MCC</u>

C. Acute myocardial infarction discharged alive with MCC

D. Extensive OR procedure unrelated to principal diagnosis without MCC/CCs

Question

The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program. The plan is to use case mix index (CMI) as a metric of CDI performance. How will this metric be measured?

A. Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI

B. Month-to-month and focus on patient volumes to raise the overall CMI

<u>C. Over time with a focus on particular documentation improvement areas in addition to the overall CMI</u>

D. Month-to-month to show CMI variability as a barometer of a specific month

Question

A 69-year-old female patient was admitted with shortness of breath, chest pain, nausea, and dizziness. The final diagnosis by the attending provider was “rule out myocardial infarction (MI).” Troponin and electrocardiogram (EKG) came back within normal limits. The clinical documentation integrity practitioner (CDIP) sends the provider a query. What should be the purpose of the query?

Choices

A. To clarify the final diagnosis

B. To specify type of chest pain

C. To determine the site of the MI

<u>D. To document angina</u>

Question

What type of query is noncompliant when used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

A. Verbal

B. Open-ended

<u>C. Yes/No</u>

D. Multiple-choice

Question

A patient treated for an abnormal heart rhythm for more than one week but less than twelve months would have which type of atrial fibrillation?

A. Chronic

<u>B. Persistent</u>

C. Permanent

D. Paroxysmal

Question

A pathologist’s report lists ovarian cancer for a patient admitted as an inpatient. The attending documents ovarian mass in the discharge summary. The most appropriate next step is to:

A. Code ovarian mass

B. Code ovarian cancer

C. Query the pathologist

<u>D. Query the attending</u>

Question

A resident returns to the long-term care facility following hospital care for pneumonia. The physician’s orders and progress note state “Continue IV antibiotics for pneumonia – 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia.” Is it appropriate to code the pneumonia in this scenario?

<u>A. Yes, J18.9, Pneumonia, unspecified organism, should be coded until the condition is resolved.</u>

B. No, since the patient needed a repeat x-ray, the condition does not clarify as a diagnosis.

C. Yes, J18.9, Pneumonia, unspecified organism, Z79.2, should be coded along with long term antibiotics.

D. Yes, J18.8, Pneumonia, other specified organism.

Question

Data collected by agencies external to the organization impact accreditation status, reimbursement, and:

<u>A. Provided services</u>

B. Patient perceptions

C. Surgery staffing

D. Bed count

Question

Which of the following indicates a noncompliant multiple-choice query?

A. Options provided are not in alphabetical order

B. A minimum of four options are presented

C. Options are clinically relevant

<u>D. Provider unable to add their own response</u>

Question

While reviewing the health record, the inpatient clinical documentation integrity (CDI) specialist notices a history of acute kidney injury (AKI) with acute tubular necrosis (ATN). The next step the CDI specialist should take is:

A. Code only the AKI

B. Query the attending to see if he/she agrees with the nephrologist’s findings

<u>C. Query the attending to clarify if the ATN resolved or was ruled out</u>

D. Code the ATN

Question

A type 1 diabetic patient is admitted to hospital for acute hemorrhage due to perforated intestinal ulcer. In this case, the diabetes would be:

<u>A. Comorbid condition</u>

B. External cause

C. No significance

D. Not coded

Question

A clinical documentation integrity (CDI) team is educating physicians on ways to improve documentation of patient severity of illness and risk of mortality. What should be included in this education?

A. Origin of patient’s diagnostic related group assignment

<u>B. Specificity about aspects of the patient’s disease</u>

C. Document patient conditions that are no longer present

D. Documentation of patient’s discharge disposition

Question

Establishing diagnostic terms which are inconsistent with symptoms, manifestations, and documentation irregularities to incorporate into documentation improvement plans are referred to as:

A. Encounters

B. Financial statements

C. Quality principles

<u>D. Definition standards</u>

Question

A clinical documentation integrity practitioner (CDIP) is performing a retrospective review on all outpatient arthroscopy surgeries performed on the shoulder and knee. Which official guidelines should the CDIP adhere to in this record review?

A. HCPCS rules established by AHIMA

<u>B. UHDDS guidelines for coding and reporting</u>

C. AHRQ guidelines for coding and reporting

D. CPT rules established by AMA

Question

A hospital’s clinical documentation integrity (CDI) staff reviews 65% of admissions. This statistic indicates that the CDI department should:

A. Review the adjusted case mix index

<u>B. Identify more query opportunities</u>

C. Increase productivity

D. Hire additional staff

Question

A 64-year-old patient presented to the emergency department after falling from his bike and sustaining a severe centimeter laceration to the right lower extremity. After local anesthesia was administered, the laceration was repaired in standard fashion using one layer of nylon sutures. What is the correct current procedural terminology (CPT) code assignment for this procedure?

A. 12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm

B. 12042 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm to 7.5 cm

C. 12032 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm

<u>D. 12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm</u>

Question

The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to:

A. Create synergy between clinical education and CDI principles

<u>B. Show a direct relationship between clinical documentation and quality patient care</u>

C. Provide community education to healthcare consumers

D. Promote CDI functions so that physicians view the CDI staff as a value-added service

Question

The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to:

A. Create synergy between clinical education and CDI principles

<u>B. Show a direct relationship between clinical documentation and quality patient care</u>

C. Provide community education to healthcare consumers

D. Promote CDI functions so that physicians view the CDI staff as a value-added service

Question

Hospital-employed physicians are more likely to be receptive to incorporating clinical documentation integrity (CDI) outcomes data into:

A. Practice contracts

<u>B. Practice guidelines</u>

C. Peer review

D. Quality review

Question

The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?

A. Audit focused cases by physicians that have a higher SOI/ROM for education plan

B. Audit cases for missed diagnosis by the CDI practitioner to target in the education plan

<u>C. Audit focused APR-DRGs and develop education plan for CDI team and physicians</u>

D. Audit cases that have high SOI/ROM assigned by coders for education and follow-up

Question

A hospital’s internal medicine department is comprised of 34 physicians. During the month of September, the query response rate for the entire internal medicine department is 82%. However, it is noted that the individual query response rate for one doctor, who recently joined the internal medicine department, is 14%. With whom should the clinical documentation integrity practitioner (CDIP) schedule a meeting to resolve the unanswered queries for this doctor?

A. Chief operations officer

B. Chief executive officer

<u>C. Clinical documentation integrity physician advisor/champion</u>

D. Health information management director