AHIMA CDIP Online Practice Questions and Exam Preparation

AHIMA CDIP Online Questions & Answers

• Question 11:

  After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?

  A. Expand the CDI program to larger areas in outpatient clinics
  B. Prioritize to focus on efforts with the largest return on investment
  C. Identify key metrics to develop program measures for coders
  D. Establish a CDI steering committee to build a strong foundation
  D. Establish a CDI steering committee to build a strong foundation

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  Explanation/Reference:

  A CDI steering committee is a group of interdisciplinary leaders who oversee and guide the CDI program's objectives, outcomes, and metrics. The committee should include representatives from finance, clinical, coding, quality, and other areas that are impacted by CDI. The committee should meet regularly to review the CDI program's performance, identify opportunities for improvement, and provide support and education to the CDI staff and providers. A CDI steering committee can help reinvigorate a stagnant CDI program by ensuring that it aligns with the organization's vision and mission, addresses the current challenges and needs, and fosters collaboration and communication among stakeholders. The other options are not necessarily effective ways to reinvigorate a CDI program. Expanding the CDI program to larger areas in outpatient clinics may not be feasible or appropriate without a clear strategy and plan. Prioritizing to focus on efforts with the largest return on investment may not reflect the true value and quality of the CDI program. Identifying key metrics to develop program measures for coders may not capture the full scope and impact of the CDI program.

• Question 12:

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

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  Explanation/Reference:

  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 13:

  Which of the following should be examined when developing documentation integrity projects?

  A. Query rates from coding staff
  B. CC and MCC capture rates
  C. Coding productivity statistics
  D. Physician satisfaction surveys
  B. CC and MCC capture rates

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  Explanation/Reference:

  The factor that should be examined when developing documentation integrity projects is CC and MCC capture rates. CC stands for complication or comorbidity, and MCC stands for major complication or comorbidity. These are secondary diagnoses that affect the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality measures of the hospital. CC and MCC capture rates measure how well the clinical documentation reflects the presence and impact of these conditions on the patient's care. Examining CC and MCC capture rates can help to identify documentation improvement opportunities, goals, strategies, and outcomes4 References: 1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 4: https://my.ahima.org/store/product?id=67077

• Question 14:

  Which of these medical conditions would a clinical documentation integrity practitioner (CDIP) expect to be treated with Levophed?

  A. Septic shock
  B. Acute respiratory failure
  C. Multiple sclerosis
  D. Acute kidney failure
  A. Septic shock

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  Explanation/Reference:

  Levophed is a brand name of norepinephrine, a medication that is similar to adrenaline and acts as a vasopressor, meaning that it constricts blood vessels and increases blood pressure. Levophed is indicated to raise blood pressure in adult patients with severe, acute hypotension (low blood pressure) that can occur with certain medical conditions or surgical procedures1. One of these conditions is septic shock, which is a life-threatening complication of sepsis, a systemic inflammatory response to infection. Septic shock is characterized by persistent hypotension despite adequate fluid resuscitation, along with signs of organ dysfunction and tissue hypoperfusion. Levophed is used as a first-line vasopressor agent in septic shock to restore adequate perfusion pressure and tissue oxygenation. Acute respiratory failure, multiple sclerosis, and acute kidney failure are not indications for Levophed treatment. Acute respiratory failure is a condition in which the lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from the blood. It can be caused by various lung diseases, injuries, or infections. The treatment of acute respiratory failure depends on the underlying cause and the severity of the condition, but it may include oxygen therapy, mechanical ventilation, medications to treat infections or inflammation, or other supportive measures. Multiple sclerosis is a chronic autoimmune disease that affects the central nervous system, causing inflammation, demyelination, and axonal damage. The symptoms of multiple sclerosis vary depending on the location and extent of the nerve damage, but they may include vision problems, numbness, weakness, fatigue, cognitive impairment, or pain. The treatment of multiple sclerosis aims to reduce the frequency and severity of relapses, slow the progression of disability, and manage the symptoms. It may include immunomodulatory drugs, corticosteroids, symptomatic medications, physical therapy, or other interventions. Acute kidney failure is a condition in which the kidneys suddenly lose their ability to filter waste products and fluids from the blood. It can be caused by various factors that impair the blood flow to the kidneys, damage the kidney tissue, or block the urine output. The symptoms of acute kidney failure may include decreased urine output, fluid retention, nausea, confusion, or shortness of breath. The treatment of acute kidney failure depends on the underlying cause and the severity of the condition, but it may include fluid management, electrolyte replacement, dialysis, medications to treat infections or inflammation, or other supportive measures.

  References:

  CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN:

  9781584268530

  Levophed Uses, Side Effects and Warnings - Drugs.com Levophed (Norepinephrine Bitartrate): Uses, Dosage ... - RxList Levarterenol, Levophed (norepinephrine) dosing ... - Medscape [Septic Shock: Practice Essentials ... - Medscape

  Reference] [Surviving Sepsis Campaign: International Guidelines for ... - PubMed] [Acute respiratory failure: MedlinePlus Medical Encyclopedia] [Multiple sclerosis - Symptoms and causes - Mayo Clinic] [Acute kidney failure - Symptoms and

  causes - Mayo Clinic]

• Question 15:

  A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

  A. query the provider to see if acute on chronic respiratory failure is supported by the health record
  B. query the provider to see if chronic respiratory failure is supported by the health record
  C. code the diagnoses of COPD exacerbation and chronic respiratory failure
  D. query the provider to see if respiratory insufficiency is supported by the health record
  A. query the provider to see if acute on chronic respiratory failure is supported by the health record

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  Explanation/Reference:

  According to the AHIMA/ACDIS Query Practice Brief, one of the scenarios that warrants a query is when there is clinical evidence of a higher degree of specificity or severity1. In this case, the patient's COPD exacerbation and oxygen therapy may indicate a higher level of respiratory impairment than chronic respiratory failure alone. Therefore, a query to the provider to see if acute on chronic respiratory failure is supported by the health record is appropriate and compliant. Acute on chronic respiratory failure is a more specific and severe diagnosis that may affect the patient's severity of illness, risk of mortality, and reimbursement2. The other options are not correct because they either assume a diagnosis without querying the provider, or query for a less specific or severe diagnosis than what the clinical indicators suggest. References: Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA QandA: Respiratory failure in a drug overdose | ACDIS

• Question 16:

  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
  B. Require physicians to document responses in charts

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  Explanation/Reference:

  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

• Question 17:

  Hospital-acquired condition pay provisions apply only to

  A. inpatient prospective payment system hospitals
  B. critical access hospitals
  C. long-term acute care hospitals
  D. inpatient psychiatric hospitals
  A. inpatient prospective payment system hospitals

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  Explanation/Reference:

  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

• Question 18:

  When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to

  A. code the first condition listed
  B. query for clarification
  C. not code either diagnosis
  D. code both diagnoses
  D. code both diagnoses

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  Explanation/Reference:

  When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to code both diagnoses, as long as they are not mutually exclusive. Comparative contrasting diagnoses are those that are considered as possible alternatives or differentials for the patient's condition, such as pneumonia versus bronchitis, or appendicitis versus diverticulitis. Coding both diagnoses will capture the clinical uncertainty and complexity of the case, and will allow for accurate reporting and reimbursement. References: : https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf : https://my.ahima.org/store/product?id=67077

• Question 19:

  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
  B. Patient identification and demographic accuracy

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  Explanation/Reference:

  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 20:

  Identify the error in the following query:

  This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin- converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?

  A. The query is unclear.
  B. The query contains irrelevant information.
  C. The query does not contain clinical indicators.
  D. The query is leading.
  D. The query is leading.

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  Explanation/Reference:

  A leading query is one that suggests a specific diagnosis, condition, or treatment to the provider, or implies that a certain response is desired or expected. A leading query can compromise the integrity and accuracy of the documentation and the coded data, and may also raise compliance and ethical issues. A query should be non-leading, meaning that it presents the facts from the health record without bias or influence, and allows the provider to use their clinical judgment to determine the appropriate response. The query in the question is leading because it implies that the patient's CHF is systolic by asking a yes/no question that only offers one option. A non-leading query would ask an open-ended question that offers multiple options, such as "What type of CHF does this patient have?" or "Please specify the type of CHF: systolic, diastolic, or combined." References: CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Guidelines for Achieving a Compliant Query Practice--2022 Update | ACDIS Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA The Provider Query Toolkit: A Guide to Compliant Practices