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AHIMA Certified Documentation Integrity Practitioner Sample Questions (Q73-Q78):
NEW QUESTION # 73
The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?
- A. Update medical records with unsigned physician responses
- B. Require the CDIP to call physicians to follow up
- C. Allow physician responses via e-mail
- D. Provide education to physicians on query process
Answer: D
Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, one of the best practices for a compliant query process is to provide ongoing education to physicians on the importance of documentation integrity, the query process, and the impact of documentation on quality measures, reimbursement, and compliance1. Education can help physicians understand the rationale and expectations for responding to queries, as well as the benefits of accurate and complete documentation for patient care and data quality. Education can also address any barriers or challenges that physicians may face in responding to queries, such as time constraints, technology issues, or workflow preferences1. References:
AHIMA/ACDIS Query Practice Brief - Updated 12/2022
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
NEW QUESTION # 74
Which of the following can be evidence of physician-hospital alignment?
- A. A high physician response rate
- B. A high clinical documentation integrity practitioner (CDIP) query rate
- C. A low physician agreement rate
- D. A high physician agreement rate
Answer: D
Explanation:
Explanation
A high physician agreement rate can be evidence of physician-hospital alignment because it indicates that the physicians are supportive of the clinical documentation integrity (CDI) program and its goals, and that they are willing to provide accurate and complete documentation in response to CDI queries. A high physician agreement rate also reflects a positive relationship and communication between the CDI team and the physicians, as well as a mutual understanding of the benefits of CDI for patient care, quality reporting, and reimbursement. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
NEW QUESTION # 75
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. Risk of mortality
- B. Severity of illness
- C. Case mix index
- D. Outcome measures
Answer: D
Explanation:
Explanation
Outcome measures are indicators of the quality of care provided by a healthcare organization, such as mortality rates, readmission rates, hospital-acquired conditions, patient safety indicators, and patient satisfaction scores. These measures are used by CMS to evaluate and compare the performance of hospitals and other providers under various pay-for-performance programs, such as value-based purchasing, hospital readmissions reduction program, hospital-acquired condition reduction program, and hospital inpatient quality reporting program. A CDI program can influence these outcome measures by ensuring that the clinical documentation accurately reflects the severity of illness, risk of mortality, and complexity of care of the patients. This can help to improve the risk adjustment and case mix index of the organization, as well as to identify and prevent potential quality issues.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) CDIP Exam Preparation Guide (https://my.ahima.org/store/product?id=67077)
NEW QUESTION # 76
A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to
- A. query the provider to see if respiratory insufficiency is supported by the health record
- B. query the provider to see if chronic respiratory failure is supported by the health record
- C. query the provider to see if acute on chronic respiratory failure is supported by the health record
- D. code the diagnoses of COPD exacerbation and chronic respiratory failure
Answer: C
Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, one of the scenarios that warrants a query is when there is clinical evidence of a higher degree of specificity or severity1. In this case, the patient's COPD exacerbation and oxygen therapy may indicate a higher level of respiratory impairment than chronic respiratory failure alone. Therefore, a query to the provider to see if acute on chronic respiratory failure is supported by the health record is appropriate and compliant. Acute on chronic respiratory failure is a more specific and severe diagnosis that may affect the patient's severity of illness, risk of mortality, and reimbursement2. The other options are not correct because they either assume a diagnosis without querying the provider, or query for a less specific or severe diagnosis than what the clinical indicators suggest.
References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Q&A: Respiratory failure in a drug overdose | ACDIS
NEW QUESTION # 77
After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?
- A. Identify key metrics to develop program measures for coders
- B. Establish a CDI steering committee to build a strong foundation
- C. Prioritize to focus on efforts with the largest return on investment
- D. Expand the CDI program to larger areas in outpatient clinics
Answer: B
Explanation:
Explanation
A CDI steering committee is a group of interdisciplinary leaders who oversee and guide the CDI program's objectives, outcomes, and metrics. The committee should include representatives from finance, clinical, coding, quality, and other areas that are impacted by CDI. The committee should meet regularly to review the CDI program's performance, identify opportunities for improvement, and provide support and education to the CDI staff and providers. A CDI steering committee can help reinvigorate a stagnant CDI program by ensuring that it aligns with the organization's vision and mission, addresses the current challenges and needs, and fosters collaboration and communication among stakeholders. The other options are not necessarily effective ways to reinvigorate a CDI program. Expanding the CDI program to larger areas in outpatient clinics may not be feasible or appropriate without a clear strategy and plan. Prioritizing to focus on efforts with the largest return on investment may not reflect the true value and quality of the CDI program. Identifying key metrics to develop program measures for coders may not capture the full scope and impact of the CDI program.
NEW QUESTION # 78
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