AHIMA AHIMA Certifications CDIP Questions & Answers

• Question 131:

  A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?

  A. Queries are limited to non-leading questions

  B. Non-responses to written queries are grounds for discipline

  C. Primary care physicians must answer written queries

  D. Queries for illegible chart notes are unnecessary

  Correct Answer: A

  According to the AHIMA best practice for written queries, queries should be limited to non- leading questions that do not imply a specific answer or diagnosis, but rather ask for the provider's opinion based on their clinical judgment and the evidence in the health record. Non-leading questions help to ensure that the query is compliant, objective, and respectful of the provider's authority and autonomy. Leading questions, on the other hand, may introduce bias, influence the provider's response, or compromise the integrity of the documentation and coding. For example, a non-leading query for a patient with chest pain would be: "What is the etiology of the chest pain?" A leading query would be: "Is the chest pain due to acute myocardial infarction?" 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 132:

  An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?

  A. Send a clinical validation query for only the diagnosis of sepsis.

  B. Send a clinical validation query for both the diagnoses of sepsis and UTI.

  C. A clinical validation query is not required for either diagnosis.

  D. Send a clinical validation query for only the diagnosis of UTI.

  Correct Answer: B

  According to the Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1, clinical validation is a process by which documentation is evaluated to ensure that the medical record demonstrates enough clinical support for all documented diagnoses as mandated by the False Claims Act. If there is a lack of clinical support for sepsis or UTI within the documentation, a clinical validation query should be sent. Query choices should list sepsis or UTI as ruled out versus ruled in (because the physician is documenting sepsis or UTI), but the query choice should also ask the provider to provide additional clinical support within the medical record. Additional query choices that are supported by clinical indicators listed on the query should also be listed as appropriate1. In this case, the patient was admitted with a fever, cough, and leukocytosis, which are signs and symptoms of sepsis or UTI. However, three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal, which are indicators that sepsis or UTI may not be present or resolved. Therefore, there is a discrepancy between the documented diagnoses of sepsis and UTI and the clinical evidence in the record. A clinical validation query should be sent to clarify if sepsis and UTI are still valid diagnoses or if they have been ruled out after study. The query should also request additional documentation of any other clinical indicators that support the diagnosis of sepsis or UTI, such as vital signs, physical exam findings, inflammatory markers, imaging results, etc1. References: Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1

• Question 133:

  Automated registration entries that generate erroneous patient identification--possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit--is an example of a potential breach of:

  A. Authorship integrity

  B. Patient identification and demographic accuracy

  C. Documentation integrity

  D. Auditing integrity

  Correct Answer: B

  Patient identification and demographic accuracy is the process of ensuring that the patient's identity and personal information are correctly recorded and verified in the health record and other systems. A potential breach of this process could result in automated registration entries that generate erroneous patient identification, which could lead to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit2 Authorship integrity is the process of ensuring that the source and content of the health record are authentic, accurate, complete, and consistent. Documentation integrity is the process of ensuring that the health record reflects the patient's clinical status, treatment, and outcomes. Auditing integrity is the process of ensuring that the health record is reviewed and monitored for compliance, quality, and improvement purposes2

  1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 2: https://my.ahima.org/store/product?id=67077

• Question 134:

  A hospital administrator wants to initiate a clinical documentation integrity (CDI) program and has developed a steering committee to identify performance metrics. The CDI manager expects to use a case mix index as one of the metrics. Which other metric will need to be measured?

  A. Comparison of risk of mortality with diagnostic related group capture rates

  B. Assessment of APR-DRGs with capture of CC or MCC

  C. Comparison of severity of illness with the CC capture rates

  D. Assessment of CC/MCC capture rates

  Correct Answer: D

  A CC/MCC capture rate is a metric that measures the percentage of cases that have at least one complication or comorbidity (CC) or major complication or comorbidity (MCC) coded in the medical record. This metric is important for a CDI program because CCs and MCCs affect the severity of illness, risk of mortality, and reimbursement of the cases under the Medicare Severity-Diagnosis Related Group (MS-DRG) system. A higher CC/MCC capture rate indicates a more accurate and complete documentation of the patient's condition and the resources used to treat them. A CDI program can use this metric to monitor the effectiveness of its queries, education, and feedback to the providers and coders. A CDI program can also compare its CC/MCC capture rate with national or regional benchmarks to identify areas of improvement or best practices 2. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: The Natural History of CDI Programs: A Metric-Based Model 4

• Question 135:

  Which of the following is nonessential to facilitate code capture when educating clinical staff on documentation practices associated with diabetes mellitus?

  A. Type

  B. Manifestation

  C. Cause

  D. Age

  Correct Answer: D

• Question 136:

  AHIMA suggests which of the following for an organization to consider as physician response rate and agreement rate?

  A. 80%/40%

  B. 80%/80%

  C. 75%/75%

  D. 70%/50%

  Correct Answer: B

  AHIMA suggests that an organization should consider a physician response rate of 80% and an agreement rate of 80% as benchmarks for CDI program performance. These rates indicate the level of physician engagement and

  documentation accuracy in relation to CDI queries.

  References: AHIMA. "Guidelines for Achieving a Compliant Query Practice (2019 Update)." Journal of AHIMA 90, no. 2 (February 2019): 20-29.

• Question 137:

  What policies should query professionals follow?

  A. AHIMA's policies related to querying

  B. All healthcare entity's policies are the same

  C. Their healthcare entity's internal policies related to querying

  D. CMS's policies related to querying

  Correct Answer: C

  Query professionals should follow their healthcare entity's internal policies related to querying, as they may vary depending on the organization's size, structure, scope, and goals. The internal policies should be based on industry best practices and standards, such as those provided by AHIMA and ACDIS, as well as applicable laws and regulations, such as those from CMS and OIG. However, AHIMA's and CMS's policies are not binding for all healthcare entities, and they may not address all the specific situations and challenges that query professionals may encounter. Therefore, query professionals should be familiar with their own healthcare entity's policies and procedures for querying, such as the query format, content, timing, delivery method, escalation process, retention, and audit. The other options are incorrect because they do not reflect the diversity and complexity of query policies across different healthcare entities.

• Question 138:

  Which of the following is an appropriate first step to address physicians with low query response rates?

  A. An educational session between the clinical documentation integrity practitioner (CDIP) and physician

  B. The medical staff review the physician's noncompliance to consider sanctions

  C. The physician receives a suspension until query responses are improved

  D. A meeting between the physician advisor/champion and the noncompliant physician

  Correct Answer: A

  An appropriate first step to address physicians with low query response rates is an educational session between the clinical documentation integrity practitioner (CDIP) and physician because it provides an opportunity to explain the purpose and benefits of the query process, to identify and address any barriers or challenges to responding, and to offer feedback and guidance on how to improve query response rates. An educational session can also help to build rapport and trust between the CDIP and the physician, and to demonstrate respect and professionalism. (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2 Understanding CDI Metrics3

• Question 139:

  A clinical documentation integrity practitioner (CDIP) is reviewing an outpatient surgical chart. The patient underwent a laparoscopic appendectomy for acute gangrenous appendicitis. Which coding reference should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment classification (APC) reimbursement?

  A. The Merck Manual

  B. AHA Coding Clinic for ICD-10-CM/PCS

  C. O AMA CPT Assistant

  D. O ICD-10-CM/PCS Codebook

  Correct Answer: C

  The coding reference that should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment classification (APC) reimbursement is the AMA CPT Assistant. The CPT Assistant is the official source of guidance from the American Medical Association (AMA) on the proper use and interpretation of the Current Procedural Terminology (CPT) codes, which are used to report outpatient and professional services. The CPT Assistant provides clinical scenarios, frequently asked questions, coding tips, and updates on CPT coding changes. The CPT codes are used to determine the APC reimbursement for outpatient services under the Medicare Outpatient Prospective Payment System (OPPS). (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2 AMA CPT Assistant3 Medicare Claims Processing Manual Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS)

• Question 140:

  Proposed changes to the inpatient prospective payment system (IPPS) take effect on

  A. October 1

  B. January 1

  C. July 1

  D. April 1

  Correct Answer: A

  Proposed changes to the inpatient prospective payment system (IPPS) take effect on October 1 of each fiscal year (FY), which begins on October 1 and ends on September 30 of the next calendar year. The IPPS final rule is usually issued by the Centers for Medicare and Medicaid Services (CMS) around August 1 of each year, and it updates the Medicare payment policies and rates for acute care hospitals and long-term care hospitals for the upcoming FY. The effective date of the final rule is October 1, unless otherwise specified by CMS 2. References: 1: Inpatient Prospective Payment System (IPPS) 2023 Final Rule Summary of ... 3 2: Acute Inpatient PPS | CMS 1