AHIMA AHIMA Certifications CDIP Questions & Answers

• Question 111:

  The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA's Guidelines for Achieving a Compliant Query Practice?

  A. Complete the documentation immediately after the provider's response

  B. Complete the documentation at the end of the day when entering cases reviewed

  C. Complete the documentation when there is a provider agreement

  D. Complete the documentation at the time of discussion or immediately following

  Correct Answer: D

  According to AHIMA's Guidelines for Achieving a Compliant Query Practice, the clinical documentation integrity practitioner (CDIP) should complete the documentation at the time of discussion or immediately following to avoid a compliance risk for this follow up failure. This is because verbal queries are considered part of the health record and must be documented in a timely and accurate manner to reflect the provider's response and any changes in documentation or coding. Completing the documentation later or only when there is an agreement may result in errors, omissions, inconsistencies, or delays that may affect the quality and integrity of the health record and the query process. (AHIMA Guidelines for Achieving a Compliant Query Practice1) References: AHIMA Guidelines for Achieving a Compliant Query Practice1

• Question 112:

  The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.

  What should the CDI manager keep in mind when discussing this observation with physicians?

  A. The indicator is a key factor of measurement for quality reports.

  B. The query rate is too high while the agreement rate is low.

  C. The query response rate directly correlates to quality reports.

  D. The diagnosis with a higher degree of specificity has a lower severity of illness.

  Correct Answer: A

  According to the AHIMA CDIP Exam Preparation Guide, one of the CDI metrics and statistics that CDI managers should track and interpret is the severity level measured against average length of stay (ALOS)1. This indicator reflects the complexity and acuity of the patient population and the quality of care provided by the hospital2. A low-severity level with a high ALOS may indicate under-documentation or under-coding of the patient's condition, which may affect the hospital's reimbursement, risk adjustment, and quality scores3. Therefore, the CDI manager should keep in mind that this indicator is a key factor of measurement for quality reports when discussing this observation with physicians, and educate them on the importance of documenting and coding accurately and completely to reflect the patient's true severity of illness. The other options are not correct because they do not address the issue of severity level measured against ALOS, or they are not relevant to the CDI manager's role or responsibility. References: CDIP Exam Preparation Guide - AHIMA Demystifying and communicating case-mix index - ACDIS Severity of Illness: What Is It? Why Is It Important? | HCPro

• Question 113:

  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?

  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

  Correct Answer: D

  The first step the CDI director should take is to gather data on the incidence of inaccurate record documentation because it is important to establish the baseline and scope of the problem, as well as to identify the potential causes and consequences of over-using electronic copy and paste. Data collection can help to measure the frequency, severity, and impact of documentation errors, such as inconsistencies, redundancies, contradictions, or omissions. Data collection can also help to determine the best methods and tools for conducting the documentation integrity project, such as audits, surveys, interviews, or software applications. (CDIP Exam Preparation Guide1) References: CDIP ontent Outline2 CDIP Exam Preparation Guide1

• Question 114:

  A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101?Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents "right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis".

  What is the proper sequencing of the principal and secondary diagnoses?

  A. Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis

  B. Right lower quadrant abdominal pain, fever, vomiting, leukocytosis

  C. Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus

  D. Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus

  Correct Answer: D

  The proper sequencing of the principal and secondary diagnoses in this case is as follows: Principal diagnosis: Acute appendicitis. This is the condition, after study, that occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. The patient was admitted for laparoscopic surgery, which is a definitive treatment for acute appendicitis. The physician documented "possible acute appendicitis or probable Meckel diverticulitis" as the cause of the right lower quadrant abdominal pain. According to the AHA's Coding Clinic, Fourth Quarter 2016, pp. 147-148, when a physician documents two diagnoses connected by "or", coders should query the physician for clarification if possible. However, if a query is not possible or not answered, coders should assign codes for both conditions, unless one of them has been ruled out or confirmed by further testing or treatment. In this case, there is no indication that either acute appendicitis or Meckel diverticulitis has been ruled out or confirmed by further testing or treatment. Therefore, both conditions should be coded and reported. However, only one of them can be the principal diagnosis. Since acute appendicitis is more commonly associated with laparoscopic surgery than Meckel diverticulitis, and since it has a higher relative weight than Meckel diverticulitis under the MS-DRG system, it is reasonable to select acute appendicitis as the principal diagnosis 23. Secondary diagnosis: Right lower quadrant abdominal pain. This is a sign or symptom that is associated with the principal diagnosis and requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. The patient presented with right lower quadrant abdominal pain as a manifestation of acute appendicitis or Meckel diverticulitis. The pain required clinical evaluation by abdominal ultrasound and therapeutic treatment by laparoscopic surgery. Therefore, it should be coded and reported as a secondary diagnosis 4. Secondary diagnosis: Type I diabetes mellitus. This is a chronic condition that affects the patient's care in terms of requiring diagnostic or therapeutic services or affecting patient outcomes or resource utilization. The patient has a history of type I diabetes mellitus and received an injection of neutral protamine Hagedorn insulin to normalize the blood sugar level prior to surgery. Therefore, it should be coded and reported as a secondary diagnosis 4. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section II.A 3: AHA Coding Clinic for ICD- 10-CM and ICD-10-PCS, Fourth Quarter 2016 4: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section III.C : AHIMA CDIP Exam Prep, Fourth Edition https://my.ahima.org/store/product?id=67077

• Question 115:

  When a change in departmental workflow is necessary, the first step is to

  A. define the gaps and solutions

  B. set realistic timelines

  C. re-engineer the process

  D. assess the current workflow

  Correct Answer: D

  The first step in changing a departmental workflow is to assess the current workflow and identify the problems or inefficiencies that need to be addressed. This will help to define the gaps and solutions, set realistic timelines, and re-engineer the process. References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 125- 126.

• Question 116:

  The best approach in resolving unanswered queries is to

  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

  Correct Answer: B

  facilities must develop an escalation policy for unanswered queries and address any medical staff concerns regarding queries1. If a query does not receive an appropriate professional response, the case should be referred for further review in accordance with the facility's written escalation policy2. The escalation policy should address when the issue is brought to the physician advisor, the department director, or administration with defined actions as to the responsibilities at each level1. The policies should reflect a method of response that can realistically occur for the organization1. Therefore, reviewing the facility's query policies and procedures is the best approach to ensure compliance and consistency in handling unanswered queries. The other options are not advisable because they either involve skipping the escalation policy, notifying the physician advisor/champion without proper review or feedback, contacting the physician repeatedly without respecting their time or availability, or notifying the coding team without resolving the query issue.

• Question 117:

  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

  Correct Answer: A

  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 118:

  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. Allow physician responses via e-mail

  C. Provide education to physicians on query process

  D. Require the CDIP to call physicians to follow up

  Correct Answer: C

  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

• Question 119:

  A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition. Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?

  A. 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural

  B. 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma

  C. 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion

  D. 61105 Twist drill hole subdural/ventricular puncture

  Correct Answer: A

  According to the CPT code description, 61154 is the appropriate code for a burr hole procedure for evacuation of a subdural hematoma. A burr hole is a small hole made in the skull with a surgical drill to access the brain or its coverings2. A subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, which are two of the three layers that cover the brain3. The evacuation of the hematoma involves removing the clot and relieving the pressure on the brain. The other codes are not applicable for this procedure because they describe different methods of access (twist drill hole) or different purposes (biopsy or puncture)4. References: CDI Week 2020 QandA: CDI and key performance indicators1 Mayo Clinic: Burr hole2 MedlinePlus: Subdural hematoma3 CPT Code Book 20234

• Question 120:

  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?

  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

  Correct Answer: B

  According to the AHIMA/ACDIS Query Practice Brief, one of the best practices for a compliant query process is to require physicians to document their responses to queries in the health record1. This ensures that the documentation is consistent, accurate, and complete, and that the query and response are part of the permanent record. Verbal responses are not acceptable, as they do not provide a clear audit trail and may lead to errors or discrepancies in coding and billing1. Therefore, the CDI manager should educate the physicians on the importance of documenting their responses in the charts and monitor their compliance. The other options are not recommended, as they may compromise the integrity of the documentation or violate the query guidelines1. References: Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA