A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?
Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?
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?
Which of the following individuals is the first line of escalation for an unanswered query?
An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has
been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?
Which of the following is nonessential to facilitate code capture when educating clinical staff on documentation practices associated with diabetes mellitus?
A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with
influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of
oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should
be used to obtain this information?
An increase in claim denials has prompted a clinical documentation integrity (CDI) manager to engage the CDI physician advisor/champion in an effort to avoid future denials. How does this strategy impact the goal?
A hospital administrator wants to initiate a clinical documentation integrity (CDI) program and has developed a steering committee to identify performance metrics. The
CDI manager expects to use a case mix index as one of the metrics. Which other metric will need to be measured?
Which of the following is used to measure the impact of a clinical documentation integrity (CDI) program on Centers for Medicare and Medicaid Services quality performance?
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 clinical documentation integrity practitioner (CDIP) is reviewing an outpatient surgical chart. The patient underwent a laparoscopic appendectomy for acute
gangrenous appendicitis. Which coding reference should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment
classification (APC) reimbursement?
Combination codes are used to classify two diagnoses, a diagnosis with a manifestation, or a diagnosis
An organization dealing with staffing shortages has adopted a policy requiring clinical documentation integrity practitioner (CDIP) to stop reviewing any record after a major complication or co-morbidity is found. What is the unintended consequence of
this?
A clinical documentation integrity practitioner (CDIP) in an acute care hospital was asked to create new query templates for ICD-10 based on AHIMA and ACDIS
guidelines. What should the multiple-choice query format include?
Given the following ICD-10-CM Alphabetical Index entry:
Ectopic (pregnancy) 008.9
What is the meaning of the parenthesis?
A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the
organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?
A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs: BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung
disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD,
ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action
would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?
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?
What is the term used when a patient is entered in the Master Patient Index (MPI) multiple times, in different ways, resulting in multiple medical record numbers?
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
The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What
strategy should be part of a project aimed at improving these behaviors?
A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before
the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped. Which policy should the
hospital follow to avoid a compliance risk?
Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner's role within the organization?
Which of these medical conditions would a clinical documentation integrity practitioner (CDIP) expect to be treated with Levophed?
The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is
Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?
When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to
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?
Which of the following sources provide external benchmarks to examine the effectiveness of a facility's clinical documentation program?
Which of the following is an appropriate first step to address physicians with low query response rates?
Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?
An 86-year-old female is brought to the emergency department by her daughter. The patient complains of feeling tired, weak and excessive sleeping. The patient's
daughter comments that patient's mental condition has not been the same. Lab results are unremarkable except for a sodium level of 119, a BUN of 22, and a creatinine
of 1.35. The patient receives normal saline IV infusing at 100 cc/hr. The admitting diagnosis is weakness, altered mental status and dehydration. Which of the following
queries is presented in an ethical manner thus avoiding potential fraud and/or compliance issues?
A clinical documentation integrity (CDI) program that is compliant with regulations from the facility's payors results in