Free CDIP Exam Dumps Preview

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)

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 assignment 1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query 1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement 2. 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 accumulation 3. 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 hospital 4. 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

A query is noncompliant if it includes options that are not supported by the clinical indicators or the patient's condition. In this case, hypernatremia is a condition of high sodium level, not low sodium level, and it is not consistent with the treatment of 0.9% saline IV. Therefore, it is a clinically irrelevant option that may confuse or mislead the provider. A compliant query should only include options that are reasonable and plausible based on the available documentation and evidence. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3

Unbundling services falls under the False Claims Act because it is a form of coding fraud that involves billing separately for components of a related group of procedures or tests that should be billed as a single code. For example, if a provider performs a comprehensive metabolic panel, which is a blood test that measures several components of the blood, such as glucose, electrolytes, and liver enzymes, and bills for each component individually instead of using the single code for the panel, that is unbundling. Unbundling services can result in overpayment by the government and can violate the False Claims Act, which prohibits submitting false or fraudulent claims for payment to the government, including the Medicare and Medicaid programs. Violators of the False Claims Act can face civil penalties of up to three times the amount of the false claim plus an additional $11,000 per claim 23.
References:
1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4
2: Coding Fraud | VSG 5
3: False Claims Act | OIG 2

The step that the clinical documentation integrity (CDI) manager should take to help avoid future Medicare violations is to collaborate with physician advisor/champion and revenue cycle manager. The physician advisor/champion can help with educating and engaging the physicians on the importance and impact of clinical documentation on coding, reimbursement, quality measures, compliance, and patient care. The revenue cycle manager can help with analyzing and monitoring the denial trends and patterns, identifying and resolving the root causes of denials, implementing corrective actions and preventive measures, and ensuring timely and accurate claim submission and appeal processes.
References:
: (https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf)
: (https://my.ahima.org/store/product?id=67077)

According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023, the principal diagnosis is defined as "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"2. In this case, the patient was admitted with shortness of breath, productive yellow sputum, and a temperature of 101.2, which are signs and symptoms of pneumonia. The CXR confirmed the diagnosis of LLL pneumonia, which is a serious condition that requires inpatient care.
Therefore, LLL pneumonia is the principal diagnosis. The secondary diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay"2. In this case, the patient had bilateral pleural effusion and kidney failure at the time of admission, which are coexisting conditions that affect the treatment received and/or the length of stay. The renal consult documented AKI with ATN, which is a more specific diagnosis than kidney failure and reflects the severity and etiology of the condition. Therefore, AKI with ATN and bilateral pleural effusion are secondary diagnoses.
References:
CDI Week 2020 Q&A: CDI and key performance indicators1 ICD-10-CM Official Guidelines for Coding and Reporting FY 20232

According to the Documentation Integrity Practitioner (CDIP? study guide, the physician with the highest number of unanswered queries would benefit from additional education. In this case, Dr. D has the highest number of unanswered queries with 9. Unanswered queries may indicate a lack of understanding, engagement, or compliance with the query process, which may affect the quality and accuracy of clinical documentation and coding 1. Therefore, Dr. D would best benefit from additional education for unanswered queries, such as the importance of timely and appropriate query responses, the impact of queries on severity of illness, risk of mortality, and reimbursement, and the best practices for a compliant query practice 2.
References:
Q&A: What to do with unanswered queries | ACDIS
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

Sharing the mission of the CDI program should be done to ensure a clear sense of what CDI is and the CDI practitioner's role within the organization. The mission statement defines the purpose, goals, and values of the CDI program, and how it aligns with the organization's vision and strategy. The mission statement also communicates the benefits and expectations of the CDI program to various stakeholders, such as providers, executives, coders, quality staff, and patients. The mission statement can help establish the credibility, professionalism, and identity of the CDI practitioners, and guide their daily activities and decisions 2.
References:
1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3
2: Mission CDI: Guiding goals, values,
and principles 1

The member of the clinical documentation integrity (CDI) team who can help provide peer-to-peer level of education on the importance of accurate documentation and query responses is the physician advisor/ champion. The physician advisor/champion is a physician who supports and advocates for the CDI program and its goals, and who can communicate effectively with other physicians about the clinical and financial implications of documentation quality and accuracy. The physician advisor/champion can also serve as a liaison between the CDI team and the medical staff, and help to resolve any issues or conflicts that may arise from the query process. The physician advisor/champion can also provide feedback and guidance to the CDI team on clinical matters and documentation standards. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2

Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include educating physicians on the importance and impact of clinical documentation on coding, reimbursement, quality measures, compliance, and patient care. The physician advisor/champion can act as a liaison between the CDIPs and the medical staff, provide feedback and guidance on query development and resolution, and facilitate peer-to-peer education sessions on documentation best practices and standards6 References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf
6:
https://my.ahima.org/store/product?id=67077

Engaging the CDI physician advisor/champion in an effort to avoid future denials is a strategy that impacts the goal of improving documentation integrity by leveraging the influence and expertise of a physician leader who can educate, mentor, and advocate for other physicians on documentation best practices. The CDI physician advisor/champion can act as a liaison between the CDI team and the medical staff, provide feedback and guidance on complex or challenging cases, resolve conflicts or discrepancies in documentation, and promote a culture of collaboration and quality improvement. Physicians are more likely to learn and adopt documentation integrity practices from their peers who understand their clinical perspective and challenges, rather than from non-physician CDI staff or managers.
A. The CDI manager will exclusively provide education. This is incorrect because engaging the CDI
physician advisor/champion implies that the CDI manager will not be the sole source of education, but rather will partner with the physician leader to deliver effective and tailored education to the medical staff.
C. Physicians can manage the documentation integrity process. This is incorrect because engaging the
CDI physician advisor/champion does not mean that physicians will take over the responsibility of managing the documentation integrity process, which involves multiple stakeholders, such as CDI specialists, coders, quality analysts, and auditors. Rather, physicians will be more involved and supportive of the documentation integrity process as a result of the education and mentorship provided by the CDI physician advisor/champion. D. Clinicians will not require documentation integrity education. This is incorrect because engaging the CDI physician advisor/champion does not eliminate the need for documentation integrity education for clinicians, but rather enhances and facilitates it by using a peer-to-peer approach that can increase awareness, engagement, and compliance among physicians.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN:
9781584268530
Q&A: Defining roles for physician advisor/champion | ACDIS Q&A: The Role of the Physician Advisor in
CDI | ACDIS The Role of a Physician Advisor - UASI Solutions
PA/NP in Physician Champion / Advisor Role -- ACDIS Forums

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

This query option is the most compliant based on the most recent AHIMA/ACDIS query practice brief because it meets the following criteria: It is based on clinical indicators in the health record that support a reasonable and logical connection between the conditions (femur fracture and osteoporosis). It is non-leading and non-suggestive, as it does not imply a specific answer or diagnosis, but rather asks for the provider's opinion based on their clinical judgment.
It is concise and clear, as it uses simple and direct language that avoids ambiguity or confusion.
It is relevant and specific, as it addresses a clinical issue that has an impact on patient care, quality reporting, and/or reimbursement. It is consistent with clinical documentation integrity (CDI) standards and guidelines, as it follows the AHIMA/ACDIS query practice brief recommendations for query format, content, delivery, and documentation.
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)
Guidelines for Achieving a Compliant Query Practice--2022 Update (https://acdis.org/resources/guidelines-achieving-compliant-query-practice%E2%80%942022-update)

A rebilling is permissible when queries are answered after the initial bill, as long as the hospital follows the appropriate guidelines and procedures for rebilling, such as submitting a corrected claim within the timely filing limit, notifying the payer of the reason for rebilling, and documenting the query process and outcome in the health record. Rebilling may be necessary to ensure accurate coding and reporting of the patient's condition and treatment, as well as appropriate reimbursement and quality measures. [3][3] References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf
[3][3]:
https://my.ahima.org/store/product?id=67077

Hospital-acquired condition pay provisions apply only to inpatient prospective payment system hospitals because they are subject to the CMS policy that reduces payments for cases with conditions that were not present on admission. This policy is intended to encourage hospitals to improve the quality of care and prevent avoidable complications. Other types of hospitals, such as critical access hospitals, long-term acute care hospitals, and inpatient psychiatric hospitals, are not affected by this policy and are paid based on different methodologies. (CDIP Exam Preparation Guide) References: CDIP Exam Content Outline1 CDIP Exam Preparation Guide2
Hospital-Acquired Conditions (Present on Admission Indicator): Hospital ...3

The clinical documentation integrity practitioner (CDIP) should interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC) by asking the physician to indicate if the pneumonia was present on admission (POA) based on the initial chest x-ray. This is because the POA status of a condition affects its coding, reporting, and reimbursement, and it is the responsibility of the physician to document the POA status of all diagnoses. The CDIP should not assume that the pneumonia developed after admission based on the timing of symptoms or treatment, as this may not reflect the true clinical picture. The CDIP should also not ask the physician about the causal relationship between the acute kidney injury and the pneumonia, as this is not relevant to the POA status. The CDIP should also not avoid querying the physician based on the presence of another MCC, as this may compromise the accuracy and completeness of documentation. (CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline
CDIP Exam Preparation Guide
Present on Admission Reporting Guidelines

Explanation: According to the AHIMA CDIP Exam Preparation Guide, a documentation integrity project is a systematic process of identifying, analyzing, and improving the quality and accuracy of clinical documentation in the health record 1. A documentation integrity project may have various purposes, such as enhancing patient safety, improving coding and reimbursement, or complying with regulatory standards 1. One of the common issues that may affect the quality and accuracy of clinical documentation is the indiscriminate use of electronic copy and paste of patient information in records by physicians 2.
Copy and paste is a function that allows physicians to duplicate existing text in the record and paste it in a new destination, which may save time and effort, but also may introduce errors, inconsistencies, or redundancies in the documentation 2. Therefore, to quantify the extent of the problem of copy and paste, the data that should be used is the incidence of redundancies in physician notes in a sample of hospital admissions. Redundancies are repeated or unnecessary information that may clutter the record and impair its readability and reliability 3. By measuring the frequency and types of redundancies in physician notes, the hospital can assess the impact of copy and paste on the documentation quality and identify areas for improvement. The other options are not correct because they do not directly measure the problem of copy and paste. The percent of insurance billings denied due to lack of record documentation may reflect other issues besides copy and paste, such as incomplete or inaccurate documentation, coding errors, or payer policies 4. The number of coder queries regarding inconsistent physician record documentation may indicate the presence of copy and paste, but it may also depend on other factors such as coder knowledge, query guidelines, or query response rate. The results of a survey of physicians that asks about documentation practices may provide some insight into the perceptions and attitudes of physicians regarding copy and paste, but it may not reflect the actual extent or impact of the problem on the documentation quality.
References:
CDIP Exam Preparation Guide - AHIMA Auditing Copy and Paste - AHIMA Copy/Paste: Prevalence, Problems, and Best Practices - AHIMA Documentation Denials: How to Avoid Them - AAPC
[Q&A: Querying for clinical validation | ACDIS]

The abbreviation NEC stands for "not elsewhere classified" and is used in the ICD-10-CM Alphabetical Index when a specific code is not available for a condition. The coder should use the NEC notation to locate the closest existing code that matches the documented diagnosis. For example, if the physician documented a malignant neoplasm of the left upper eyelid, but the Alphabetical Index only has an entry for malignant neoplasm of eyelid NEC, then the coder should use the code C44.10 (Unspecified malignant neoplasm of unspecified eyelid, including canthus) and assign a seventh character to specify laterality.
(CDIP Exam Preparation Guide)
References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
ICD-10-CM Official Guidelines for Coding and Reporting FY 20213

The clinical documentation integrity (CDI) manager should consult the Chief Medical Officer when developing query policy and procedures because the Chief Medical Officer is responsible for overseeing the quality and safety of patient care, ensuring compliance with regulatory and accreditation standards, and providing leadership and guidance to the medical staff. The Chief Medical Officer can help to establish the goals, scope, and authority of the CDI program, as well as to support the query process and promote provider education and engagement. (CDIP Exam Preparation Guide) References: CDIP Exam Content Outline1 CDIP Exam Preparation Guide2

Explanation: This is the most compliant query based on the most recent AHIMA/ACDIS query practice brief because it is non-leading, non-suggestive, and provides multiple options for the physician to choose from.

It also does not imply any financial or quality implications for adding a diagnosis associated with the BMI.
References:
AHIMA/ACDIS. "Guidelines for Achieving a Compliant Query Practice (2019 Update)." Journal
of AHIMA 90, no. 2 (February 2019): 20-29.