AHIMA CDIP Online Practice Questions and Exam Preparation

AHIMA CDIP Online Questions & Answers

• Question 1:

  A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient's diagnosis. Which response provides the highest level of specificity?

  A. Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
  B. Acute on chronic systolic CHF with hypertensive renal disease, CKD 3
  C. Acute diastolic CHF with HTN and CKD 3
  D. Acute CHF with hypertensive renal disease, CKD 3
  A. Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3

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  Explanation/Reference:

  This response provides the highest level of specificity for the patient's diagnosis because it includes the following elements: The type of heart failure: diastolic, which means the heart has difficulty relaxing and filling with blood during diastole, resulting in increased filling pressures and pulmonary congestion. Diastolic heart failure is also known as heart failure with preserved ejection fraction (HFpEF), which is defined as an ejection fraction of 50% or higher 2. The acuity of heart failure: acute on chronic, which means the patient has a history of chronic heart failure that has worsened acutely due to a precipitating factor, such as infection, ischemia, arrhythmia, or medication noncompliance. Acute on chronic heart failure is associated with higher mortality and morbidity than stable chronic heart failure 3. The associated conditions: hypertensive renal disease and CKD 3, which indicate that the patient has kidney damage and reduced kidney function due to high blood pressure. CKD 3 is the third stage of chronic kidney disease, which is characterized by a glomerular filtration rate of 30 to 59 mL per minute per 1.73 m2 4. The other responses are less specific because they either omit or misrepresent some of these elements. For example, response B incorrectly states that the patient has systolic heart failure, which is contradicted by the echocardiogram result. Response C does not specify whether the heart failure is chronic or acute on chronic, which has implications for treatment and prognosis. Response D does not specify the type of heart failure, which affects the coding and classification of the condition. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 5 2: Heart Failure With Preserved Ejection Fraction (HFpEF) | American Heart Association 3: Acute-on-Chronic Heart Failure: A High-Risk Phenotype Needing Separate Attention 4: Chronic Kidney Disease (CKD) | National Kidney Foundation

• Question 2:

  The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

  A. look for documented conditions that have well supported accompanying clinical criteria
  B. determine if only the treatment is documented and there is no diagnosis documented
  C. watch for reportable conditions or conditions that are unambiguous or otherwise complete
  D. identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
  B. determine if only the treatment is documented and there is no diagnosis documented

• Question 3:

  Which of the following clinical documentation integrity (CDI) dashboard metrics is frequently used to help evaluate the credibility of CDI practitioner queries and the success of the CDI program?

  A. CDI agreement rate
  B. CDI query rate
  C. Provider response rate
  D. Provider agreement rate
  D. Provider agreement rate

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  Explanation/Reference:

  The provider agreement rate is the percentage of queries that result in a change in the documentation or coding that is consistent with the query. It is a measure of the accuracy and appropriateness of the queries, as well as the provider's acceptance of the CDI program's recommendations. A high provider agreement rate indicates that the CDI practitioners are asking relevant and compliant queries that improve the quality and specificity of the documentation. The other options are not directly related to the credibility of the queries or the success of the CDI program. The CDI agreement rate is the percentage of queries that agree with the coder's final DRG assignment. The CDI query rate is the percentage of records that generate a query from the CDI practitioner. The provider response rate is the percentage of queries that receive a response from the provider.

• Question 4:

  A query should be generated when the documentation is

  A. legible
  B. consistent
  C. complete
  D. conflicting
  D. conflicting

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  Explanation/Reference:

  A query should be generated when the documentation is conflicting, meaning that there is contradictory or inconsistent information in the medical record that may affect the accuracy of coding, quality reporting, or reimbursement. For example, if the documentation in the progress notes differs from the documentation in the discharge summary, or if different providers document different diagnoses or procedures for the same patient, a query may be needed to resolve the discrepancy and obtain clarification from the source of the documentation. A query should not be generated when the documentation is legible, consistent, or complete, as these are desirable characteristics of documentation that do not require further clarification or verification. References: CDIP?Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf) Accurate Documentation is Essential ?Knowing When to Query your Providers1

• Question 5:

  Which of the following falls under the False Claims Act?

  A. Missing charges
  B. Unbundling services
  C. Missing modifiers
  D. Missing diagnosis codes
  B. Unbundling services

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  Explanation/Reference:

  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

• Question 6:

  Which of the following may result in an incomplete health record deficiency being assigned to a provider?

  A. A quality query
  B. A retrospective query
  C. A concurrent query
  D. An outstanding query
  D. An outstanding query

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  Explanation/Reference:

  An outstanding query may result in an incomplete health record deficiency being assigned to a provider, if the query is not answered or resolved before the discharge or final coding of the patient. An outstanding query is a query that has been generated by the clinical documentation integrity practitioner (CDIP) or the coder, but has not been acknowledged or addressed by the provider. An outstanding query may affect the accuracy and completeness of the health record, as well as the coding, reimbursement, quality measures, and compliance of the hospital. References: : https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf : https://my.ahima.org/store/product?id=67077

• Question 7:

  When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?

  A. Admitting
  B. Consulting
  C. Surgical
  D. Credentialing
  A. Admitting

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  Explanation/Reference:

  When queries are part of the health record, which is recommended by AHIMA and ACDIS, physicians are responsible for responding to queries in a timely manner and ensuring that their documentation is complete and accurate. If a provider receives too many deficiencies due to incomplete records for failure to respond to queries, their admitting privilege could be suspended by the medical staff committee as a disciplinary action. References: AHIMA/ACDIS. "Guidelines for Achieving a Compliant Query Practice (2019 Update)." Journal of AHIMA 90, no. 2 (February 2019): 20-29.

• Question 8:

  A patient presents to the emergency room with acute shortness of breath. The patient has a history of lung cancer that has been treated previously with radiation and chemotherapy. The patient is intubated and placed on mechanical ventilation. A chest x-ray is remarkable for a pleural effusion. A thoracentesis is performed, and the cytology results show malignant cells. Diagnoses on discharge: Acute respiratory failure due to recurrence of small cell carcinoma and malignant pleural effusion. Which coding reference takes precedence for assigning the ICD-10-CM/PCS codes?

  A. Conventions and instructions of the classification for ICD-10-CM/PCS
  B. AMA CPT Assistant
  C. AHA Coding Clinic for ICD-10-CM/PCS
  D. ICD-10-CM Official Guidelines for Coding and Reporting
  A. Conventions and instructions of the classification for ICD-10-CM/PCS

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  Explanation/Reference:

  According to the CDIP?Exam Content Outline, one of the tasks of a clinical documentation integrity practitioner (CDIP) is to apply coding conventions, guidelines, and definitions for ICD-10-CM/PCS. Coding conventions are the general rules for the use of the classification system, such as the use of abbreviations, punctuation, symbols, and sequencing instructions. Coding guidelines are the official rules for selecting and reporting codes based on the documentation in the health record. Coding definitions are the explanations of the terms and concepts used in the classification system. The conventions and instructions of the classification for ICD-10-CM/PCS take precedence over any other coding reference because they are the primary source of coding rules and standards. The other coding references, such as AMA CPT Assistant, AHA Coding Clinic for ICD-10-CM/PCS, and ICD- 10-CM Official Guidelines for Coding and Reporting, are secondary sources that provide additional guidance, clarification, or interpretation of the coding conventions and instructions. References: CDIP?Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf) ICD-10-CM Features | Diagnosis Coding: Using the ICD-10-CM1

• Question 9:

  For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within 24 hours of arrival unless a contraindication to aspirin is documented. How should this be documented in the health record?

  A. The name of the medication (aspirin), the date and time it was last administered
  B. The name of the medication (aspirin), the date, time and location where it was last administered
  C. The name of the medication (aspirin) and the date it was last administered
  D. The name of the medication (aspirin), the date and location where it was last administered
  B. The name of the medication (aspirin), the date, time and location where it was last administered

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  Explanation/Reference:

  The name of the medication (aspirin), the date, time and location where it was last administered should be documented in the health record for inpatients with a discharge principal diagnosis of acute myocardial infarction, unless a contraindication to aspirin is documented. This is because aspirin is a core measure for acute myocardial infarction patients, and its administration within 24 hours of arrival is an indicator of quality of care and patient safety. The date, time and location are important to verify that the medication was given within the specified timeframe and to avoid duplication or omission of doses4 References: 1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 4: https://my.ahima.org/store/product?id=67077

• Question 10:

  Whether or not queries should be kept as a permanent part of the medical record is decided by

  A. physician preference
  B. state law
  C. federal law
  D. organizational policy
  D. organizational policy

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  Explanation/Reference:

  According to the AHIMA/ACDIS Query Practice Brief, whether or not queries should be kept as a permanent part of the medical record is decided by the organizational policy of each facility1. There is no federal or state law that mandates the retention of queries in the medical record, although some external reviewers may request copies of queries to validate the query wording and compliance2. Physician preference is not a valid factor in determining the query retention policy, as queries should be handled consistently across the organization3. Therefore, the correct answer is D. organizational policy. References: Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA QandA: Develop policies regarding query retention | ACDIS QandA: Keep query retention policies consistent | ACDIS