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CDIP Certified Documentation Integrity Practitioner Questions and Answers

Questions 4

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?

Options:

A.

Queries are limited to non-leading questions

B.

Non-responses to written queries are grounds for discipline

C.

Primary care physicians must answer written queries

D.

Queries for illegible chart notes are unnecessary

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Questions 5

Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

Options:

A.

Chief Medical Officer

B.

Compliance Officer

C.

CDI practitioner

D.

Chief Financial Officer

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Questions 6

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?

Options:

A.

No query is needed

B.

Query physician for POA

C.

Bring this case up in weekly Health Information Management meetings for further action

D.

Take the case to physician advisor/champion to discuss further action

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Questions 7

Which of the following individuals is the first line of escalation for an unanswered query?

Options:

A.

CDI Manager

B.

CDI Steering Committee

C.

Medical Director

D.

HIM/Coding Manager

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Questions 8

When are concurrent queries initiated?

Options:

A.

After the health record has been coded

B.

After discharge of the patient

C.

While the patient is hospitalized

D.

Before patient is admitted

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Questions 9

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?

Options:

A.

Send a clinical validation query for only the diagnosis of sepsis.

B.

Send a clinical validation query for both the diagnoses of sepsis and UTI.

C.

A clinical validation query is not required for either diagnosis.

D.

Send a clinical validation query for only the diagnosis of UTI.

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Questions 10

Which of the following is nonessential to facilitate code capture when educating clinical staff on documentation practices associated with diabetes mellitus?

Options:

A.

Type

B.

Manifestation

C.

Cause

D.

Age

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Questions 11

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?

Options:

A.

Physician's Desk Reference

B.

Medical Dictionary

C.

The Merck Manual

D.

AMA CPT Assistant

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Questions 12

Which of the following can be evidence of physician-hospital alignment?

Options:

A.

A high physician agreement rate

B.

A low physician agreement rate

C.

A high clinical documentation integrity practitioner (CDIP) query rate

D.

A high physician response rate

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Questions 13

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?

Options:

A.

The CDI manager will exclusively provide education.

B.

Physicians will learn documentation integrity practices from peers.

C.

Physicians can manage the documentation integrity process.

D.

Clinicians will not require documentation integrity education.

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Questions 14

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?

Options:

A.

Comparison of risk of mortality with diagnostic related group capture rates

B.

Assessment of APR-DRGs with capture of CC or MCC

C.

Comparison of severity of illness with the CC capture rates

D.

Assessment of CC/MCC capture rates

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Questions 15

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?

Options:

A.

Risk of mortality

B.

Case mix index

C.

Severity of illness

D.

Outcome measures

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Questions 16

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

Options:

A.

subsequent

B.

sequela

C.

initial

D.

aftercare

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Questions 17

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?

Options:

A.

The Merck Manual

B.

AHA Coding Clinic for ICD-10-CM/PCS

C.

O AMA CPT Assistant

D.

O ICD-10-CM/PCS Codebook

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Questions 18

Combination codes are used to classify two diagnoses, a diagnosis with a manifestation, or a diagnosis

Options:

A.

that is an integral part of a disease process

B.

with an associated complication

C.

with an associated procedure

D.

with a sequelae or late effect

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Questions 19

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?

Options:

A.

Increase in case mix index

B.

Reduced risk of clinical denials

C.

Increased number of records reviewed by each CDIP

D.

Decrease in severity of illness and risk of mortality

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Questions 20

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?

Options:

A.

Clinically insignificant options

B.

Impact on reimbursement

C.

Clinically unsupported diagnosis

D.

Clinically significant options

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Questions 21

Given the following ICD-10-CM Alphabetical Index entry:

Ectopic (pregnancy) 008.9

What is the meaning of the parenthesis?

Options:

A.

Exclusion notes

B.

Non-essential modifiers

C.

Essential modifiers

D.

Inclusion notes

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Questions 22

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?

Options:

A.

Any physician caring for the patient can correct inaccurate record notes

B.

Errors are corrected by the clinician who authored the documentation

C.

Amendments to record content must be co-signed by the attending physician

D.

Coders can rely on the laboratory results to confirm the patient's diagnosis

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Questions 23

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)?

Options:

A.

Query the physician to clarify if CXR result means patient has pneumonia.

B.

Query the physician to clarify for type of COPD such as severe asthma.

C.

Query the physician to clarify for clinical significance of the CXR results.

D.

Query the physician to clarify if patient has acute COPD exacerbation.

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Questions 24

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?

Options:

A.

Have CDI manager teaming with coding supervisor to monitor physician responses

B.

Require physicians to document responses in charts

C.

Permit CDI practitioners to document physician responses in the charts

D.

Allow physician to respond via e-mail

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Questions 25

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?

Options:

A.

Replica

B.

Clone

C.

Facsimile

D.

Overlap

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Questions 26

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

Options:

A.

code pneumonia, unspecified

B.

query the provider to see if pseudomonas sepsis is supported by the health record

C.

query the provider to document the etiology of pneumonia

D.

code pseudomonas pneumonia

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Questions 27

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?

Options:

A.

Expand use of coding queries by CDI team

B.

Add a physician advisor/champion to the CDI team

C.

Encourage physician-nurse cooperation

D.

Alter the physician documentation requirements

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Questions 28

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?

Options:

A.

A rebilling is permissible when queries are answered after the initial bill.

B.

A post-bill query rarely occurs as a result of an audit or other internal monitor.

C.

A second bill should not be submitted when the first bill was incomplete.

D.

A post bill query is not appropriate when an error is found after an audit.

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Questions 29

The best approach in resolving unanswered queries is to

Options:

A.

notify the physician advisor/champion that the physician has not responded to the query

B.

review the facility's query policies and procedures

C.

contact the physician repeatedly until he/she responds to the query

D.

notify the coding team of the physician's unanswered query

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Questions 30

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?

Options:

A.

Productivity standards

B.

Review schedule

C.

Milestones

D.

Mission

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Questions 31

Which of these medical conditions would a clinical documentation integrity practitioner (CDIP) expect to be treated with Levophed?

Options:

A.

Septic shock

B.

Acute respiratory failure

C.

Multiple sclerosis

D.

Acute kidney failure

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Questions 32

The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is

Options:

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

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Questions 33

Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?

Options:

A.

Legible

B.

Complete

C.

Reliable

D.

Precise

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Questions 34

When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to

Options:

A.

code the first condition listed

B.

query for clarification

C.

not code either diagnosis

D.

code both diagnoses

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Questions 35

What type of laboratory test is a creatinine test?

Options:

A.

Chemistry

B.

Microbiology

C.

Hematology

D.

Serology

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Questions 36

When writing a compliant query, best practice is to

Options:

A.

direct the physician to a specific diagnosis

B.

include all relevant clinical indicators

C.

use the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present

D.

use a yes/no query format for specificity of a diagnosis

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Questions 37

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?

Options:

A.

Recommend the physicians to be involved in the project

B.

Bring together a team of physicians and informatics specialists

C.

Alert senior leadership to the record documentation problem

D.

Gather data on the incidence of inaccurate record documentation

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Questions 38

Which of the following sources provide external benchmarks to examine the effectiveness of a facility's clinical documentation program?

Options:

A.

Health Care Financing Administration

B.

American Health Information Management Association

C.

Agency for Healthcare Research and Quality

D.

Medicare Provider Analysis and Review

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Questions 39

Which of the following is an appropriate first step to address physicians with low query response rates?

Options:

A.

An educational session between the clinical documentation integrity practitioner (CDIP) and physician

B.

The medical staff review the physician's noncompliance to consider sanctions

C.

The physician receives a suspension until query responses are improved

D.

A meeting between the physician advisor/champion and the noncompliant physician

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Questions 40

Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?

Options:

A.

Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)

B.

Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)

C.

Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), Office of Inspector General (OIG)

D.

Center for Improvement in Healthcare (CIHQ), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)

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Questions 41

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?

Options:

A.

Patient's sodium is 119 and she is on NS IV at 100 cc/hr, is this clinically significant? If so, please document a corresponding diagnosis related to this lab result.

B.

Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr. Is the altered mental status related to the sodium of 119?

C.

Patient's sodium is 119 and she is on NS IV at 100 cc/hr, does patient have hyponatremia?

D.

Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr, please clarify the clinical significance of the lab result.

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Questions 42

A clinical documentation integrity (CDI) program that is compliant with regulations from the facility's payors results in

Options:

A.

higher overall program cost

B.

need for more CDI staff

C.

less risk from audits

D.

meeting external benchmarks

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Exam Code: CDIP
Exam Name: Certified Documentation Integrity Practitioner
Last Update: Nov 24, 2024
Questions: 140
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