AHIMA AHIMA Certifications CDIP Questions & Answers

• Question 91:

  Which physician would best benefit from additional education for unanswered queries?

  

  A. Dr. A

  B. Dr. B

  C. Dr. C

  D. Dr. D

  Correct Answer: D

  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 coding1. 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 practice2. References: QandA: What to do with unanswered queries | ACDIS Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

• Question 92:

  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

  Correct Answer: A

  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 93:

  The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to

  A. provide community education to healthcare consumers

  B. create synergy between clinical education and CDI principles

  C. show a direct relationship between clinical documentation and quality patient care

  D. promote CDI functions so that physicians view the CDI staff as value-added service

  Correct Answer: C

  The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to show a direct relationship between clinical documentation and quality patient care. According to the web search results, CDI programs aim to improve the quality and efficiency of clinical documentation by ensuring that it is accurate, complete, and consistent. This in turn leads to better health care data, which is vital for capturing the appropriate indicators used for health care facility and provider profiling, reimbursement, risk adjustment, and quality scores12. CDI programs also focus on patient safety, by identifying and resolving any documentation omissions, discrepancies, or adverse events that may affect the patient's outcome or care3. Therefore, CDI programs demonstrate how clinical documentation can impact the quality of patient care and the performance of health care organizations.

• Question 94:

  Educating physicians on severity of illness and risk of mortality is best accomplished by utilizing

  A. the case mix index

  B. physician report cards

  C. case studies

  D. the DRG Expert

  Correct Answer: C

  Educating physicians on severity of illness and risk of mortality is best accomplished by using case studies that demonstrate how documentation affects these indicators and how they impact patient care, quality outcomes, and reimbursement. References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 97-98.

• Question 95:

  Which of the following should an organization consider when developing a query retention policy and procedure?

  A. If the query is considered part of the health record

  B. How the query will be formatted

  C. Who should be queried

  D. What the escalation process will be

  Correct Answer: A

  One of the factors that an organization should consider when developing a query retention policy and procedure is if the query is considered part of the health record or not. According to the AHIMA/ACDIS query practice brief1, a query is considered part of the health record if it meets any of the following criteria: It is used to clarify documentation that affects code assignment or other data elements It is used to support clinical validation of a diagnosis or procedure It is used to support medical necessity or quality indicators It is used to communicate clinical information between providers If a query is part of the health record, it should be retained according to the organization's health record retention policy and procedure, which should comply with federal, state, and local laws and regulations. The query retention policy and procedure should also address issues such as: The format and location of the query (e.g., paper, electronic, hybrid) The security and confidentiality of the query The accessibility and availability of the query The ownership and custodianship of the query The legal implications and evidentiary value of the query References: CDIP?ontent Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf) Guidelines for Achieving a Compliant Query Practice--2022 Update1

• Question 96:

  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. 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

  Correct Answer: B

  A strategy that should be part of a project aimed at improving the unacceptable documentation behaviors of some physicians is to add a physician advisor/champion to the CDI team. A physician advisor/champion is a physician leader who supports and advocates for the CDI program, educates and mentors other physicians on documentation best practices, resolves conflicts and barriers, and provides feedback and recognition to physicians who improve their documentation. A physician advisor/champion can help change the documentation behaviors of some physicians by using peer influence, credibility, and authority to motivate them to comply with the CDI program goals and standards. A physician advisor/ champion can also help bridge the gap between the CDI team and the physicians, and foster a culture of collaboration and quality improvement 23. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 136 4 2: The Role of Physician Advisors in Clinical Documentation Improvement Programs 5 3: Physician Advisor: The Key to Clinical Documentation Improvement Success

• Question 97:

  The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate. What might this indicate to the CDI manager?

  A. The program is successful because documentation has improved

  B. The loss of a large volume of patients has impacted workflow

  C. CDI staff need education on identifying query opportunities

  D. The decrease in hospital census has caused a lack of query opportunities

  Correct Answer: C

  A drastic drop in the physician query rate might indicate to the CDI manager that the CDI staff need education on identifying query opportunities. The physician query rate is a metric that measures the percentage of records that have at least one query sent by the CDI staff to clarify or improve the documentation. A high query rate may reflect a high level of documentation quality issues or a high level of CDI staff vigilance and expertise. A low query rate may reflect a low level of documentation quality issues or a low level of CDI staff awareness and competence 2. Therefore, a drastic drop in the query rate could suggest that the CDI staff are missing some query opportunities or are not following the query policies and procedures. The CDI manager should investigate the reasons for the drop and provide education and feedback to the CDI staff on how to identify and address query opportunities effectively and compliantly 3. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: Understanding CDI Metrics - AHIMA 2 3: The Natural History of CDI Programs: A Metric-Based Model 5

• Question 98:

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

  Ectopic (pregnancy) 008.9

  What is the meaning of the parenthesis?

  A. Exclusion notes

  B. Non-essential modifiers

  C. Essential modifiers

  D. Inclusion notes

  Correct Answer: B

• Question 99:

  A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

  A. That the blood loss was not clinically significant

  B. The associated diagnosis and the clinical rationale in the progress notes

  C. A cause-and-effect relationship between anemia and the underlying cause

  D. The associated diagnosis directly on the query form

  Correct Answer: B

  The physician needs to document the associated diagnosis and the clinical rationale in the progress notes for the CDIP to record the query as answered and agreed because this is the best way to ensure that the health record reflects the patient's condition and treatment accurately and completely. The associated diagnosis is the condition that caused or contributed to the blood loss and the need for transfusion, such as acute blood loss anemia, hemorrhage, or trauma. The clinical rationale is the explanation of how the diagnosis is supported by the clinical indicators, such as laboratory values, vital signs, symptoms, or procedures. Documenting the associated diagnosis and the clinical rationale in the progress notes also helps to avoid any confusion or inconsistency with other parts of the health record, such as the discharge summary or the coding. (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2 Guidelines for Achieving a Compliant Query Practice (2019 Update)3

• Question 100:

  In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?

  A. The latest Medicare Provider and Analysis Review data

  B. Emphasize the Medicare requirements for documentation

  C. Examples from the hospital's actual cases

  D. Explanations on how severity of illness and risk of mortality impact reimbursement

  Correct Answer: C

  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