AHIMA CDIP Online Practice Questions and Exam Preparation

AHIMA CDIP Online Questions & Answers

• Question 21:

  Which of the following individuals is the first line of escalation for an unanswered query?

  A. CDI Manager
  B. CDI Steering Committee
  C. Medical Director
  D. HIM/Coding Manager
  A. CDI Manager

  ---

  Explanation/Reference:

  The first line of escalation for an unanswered query is the CDI Manager because they are responsible for overseeing the CDI program and ensuring compliance with query policies and procedures. The CDI Manager can monitor the query response rates, identify the providers who are not responding, and communicate with them to address any issues or barriers. The CDI Manager can also provide education and feedback to the providers on the importance and benefits of timely query responses. If the CDI Manager is unable to resolve the problem, then they can escalate it to the next level, such as the Medical Director or the CDI Steering Committee. (CDIP Exam Preparation Guide) References: CDIP Exam Content Outline1 CDIP Exam Preparation Guide2 QandA: Establishing an escalation policy for inappropriate queries3

• Question 22:

  Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

  A. Chief Medical Officer
  B. Compliance Officer
  C. CDI practitioner
  D. Chief Financial Officer
  A. Chief Medical Officer

  ---

  Explanation/Reference:

  The clinical documentation integrity (CDI) manager should consult the Chief Medical Officer when developing query policy and procedures because the Chief Medical Officer is responsible for overseeing the quality and safety of patient care, ensuring compliance with regulatory and accreditation standards, and providing leadership and guidance to the medical staff. The Chief Medical Officer can help to establish the goals, scope, and authority of the CDI program, as well as to support the query process and promote provider education and engagement. (CDIP Exam Preparation Guide) References: CDIP Exam Content Outline1 CDIP Exam Preparation Guide2

• Question 23:

  A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs: BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia. Aspiration precautions and IV Clindamycin ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.

  A. Simple pneumonia
  B. Aspiration pneumonia
  C. Pneumonia, a sequela of CVA
  D. Complex pneumonia
  B. Aspiration pneumonia

  ---

  Explanation/Reference:

  Aspiration pneumonia is a type of pneumonia that occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, causing an infection or inflammation. Aspiration pneumonia is more likely to occur in people who have difficulty swallowing, such as those with a history of CVA2. In this case, the patient has a history of CVA and difficulty swallowing, and presents with nausea and vomiting, which are risk factors for aspiration. The CXR reveals a right lower lobe infiltrate, which is a common finding in aspiration pneumonia3. The physician documents pneumonia as the diagnosis, but does not specify the type or cause. Therefore, clarification is needed to determine if aspiration pneumonia is clinically indicated, as it would affect the coding and reimbursement of the case. Aspiration pneumonia is coded as ICD-10-CM code J69.x Pneumonitis due to solids and liquids, with a fourth digit required to specify the inhaled substance4. References: CDI Week 2020 QandA: CDI and key performance indicators1 Mayo Clinic: Aspiration pneumonia2 Medscape: Aspiration Pneumonia3 ICD-10-CM Diagnosis Code J69.x: Pneumonitis due to solids and liquids4

• Question 24:

  Which member of the clinical documentation integrity (CDI) team can help provide peer-to- peer level of education on the importance of accurate documentation and query responses?

  A. Chief Financial Officer
  B. Physician advisor/champion
  C. CDI practitioner
  D. CDI manager
  B. Physician advisor/champion

  ---

  Explanation/Reference:

  The member of the clinical documentation integrity (CDI) team who can help provide peer- to-peer level of education on the importance of accurate documentation and query responses is the physician advisor/champion. The physician advisor/champion is a physician who supports and advocates for the CDI program and its goals, and who can communicate effectively with other physicians about the clinical and financial implications of documentation quality and accuracy. The physician advisor/champion can also serve as a liaison between the CDI team and the medical staff, and help to resolve any issues or conflicts that may arise from the query process. The physician advisor/champion can also provide feedback and guidance to the CDI team on clinical matters and documentation standards. (CDIP Exam Preparation Guide) References: CDIP Exam Content Outline1 CDIP Exam Preparation Guide2

• Question 25:

  A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.

  White blood count BC 18,000 Temperature 101.5 Heart rate 110 Respiratory rate 24 Blood pressure 95/67 Sputum culture (+) klebsiella pneumoniae

  Which diagnosis implies that a query was sent and answered?

  A. Sepsis with respiratory failure due to pneumonia
  B. Sepsis with pneumonia due to klebsiella pneumoniae
  C. Septicemia due to klebsiella pneumoniae
  D. Severe sepsis with pneumonia due to klebsiella pneumoniae
  B. Sepsis with pneumonia due to klebsiella pneumoniae

  ---

  Explanation/Reference:

  According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear,

  concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non- leading query statement2.

  In this case, the patient presents with signs and symptoms of sepsis, such as fever, tachycardia, tachypnea, hypotension, and elevated white blood count. The patient also has a positive sputum culture for klebsiella pneumoniae, which is the

  likely source of infection. However, the hospitalist continues to document septicemia due to pneumonia, which is a vague and outdated term that does not reflect the patient's true severity of illness, risk of mortality, or reimbursement3.

  Therefore, a query to the hospitalist to clarify the diagnosis of sepsis and its etiology is appropriate and compliant. The diagnosis that implies that a query was sent and answered is B. Sepsis with pneumonia due to klebsiella pneumoniae.

  This diagnosis is more specific and accurate than septicemia due to pneumonia, as it indicates the type of infection (sepsis), the site of infection (pneumonia), and the causal organism (klebsiella pneumoniae). This diagnosis also affects the

  assignment of DRGs and quality scores. The other options are not correct because they either do not provide enough specificity ? or they introduce additional diagnoses that are not supported by the clinical indicators (A and D). References:

  CDIP Exam Preparation Guide - AHIMA

  Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA QandA: Three query opportunities related to sepsis infections | ACDIS [QandA: Clinical validation of sepsis and clinical criteria | ACDIS]

• Question 26:

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

  ---

  Explanation/Reference:

  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 27:

  Which of the following is a clinical documentation integrity (CDI) financial impact measure?

  A. Severity of illness
  B. Hierarchical condition category
  C. Case mix index
  D. Release of information
  C. Case mix index

  ---

  Explanation/Reference:

  Case mix index (CMI) is a measure of the average severity and resource consumption of a group of patients, such as those in a hospital or a diagnosis-related group (DRG). CMI reflects the financial impact of CDI by showing how documentation improvement can affect the DRG assignment and reimbursement. A higher CMI indicates more complex and costly cases, while a lower CMI indicates less complex and costly cases. CDI programs can monitor the changes in CMI over time to evaluate their effectiveness and return on investment. (Understanding CDI Metrics2) References: CDI Week 2020 QandA: CDI and key performance indicators1 Understanding CDI Metrics2

• Question 28:

  The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?

  A. Audit cases for missed diagnosis by the CDI practitioner to target in the education plan
  B. Audit focused cases by physicians that have a higher SOI/ROM for education plan
  C. Audit cases that have high SOI/ROM assigned by coders for education and follow-up
  D. Audit focused APR-DRGs and develop education plan for CDI team and physicians
  D. Audit focused APR-DRGs and develop education plan for CDI team and physicians

  ---

  Explanation/Reference:

  APR-DRGs are a patient classification system that assigns each inpatient stay to one of more than 300 base APR-DRGs, and then further stratifies each base APR-DRG into four levels of severity of illness (SOI) and risk of mortality (ROM), based on the number, nature, and interaction of complications and comorbidities (CCs) and major CCs (MCCs). SOI reflects the extent of physiologic decompensation or organ system loss of function, while ROM reflects the likelihood of dying. Both SOI and ROM are used to adjust payment rates, quality indicators, and performance measures for hospitals and other healthcare providers. The CDI manager can gain more information about the potential opportunities for improvement by auditing focused APR-DRGs that have a high impact on SOI/ROM levels, such as those that have a large variation in relative weights across the four severity levels, or those that have a high frequency or volume of cases. The audit can help identify the documentation gaps, inconsistencies, or inaccuracies that may affect the assignment of SOI/ROM levels, such as missing, vague, or conflicting diagnoses, procedures, or clinical indicators. The audit can also help evaluate the CDI team's performance in terms of query rate, response rate, agreement rate, and accuracy rate. Based on the audit findings, the CDI manager can develop an education plan for both the CDI team and the physicians to address the specific documentation improvement areas and provide feedback and guidance on best practices.

  A. Audit cases for missed diagnosis by the CDI practitioner to target in the education plan. This is not the best way to gain more information about the situation, because it may not capture all the factors that affect SOI/ROM levels, such as procedures, clinical indicators, or interactions among diagnoses. It may also focus only on the CDI practitioner's performance, without considering the physician's role in documentation quality and completeness.

  B. Audit focused cases by physicians that have a higher SOI/ROM for education plan. This is not a valid way to gain more information about the situation, because it may not identify the documentation improvement opportunities for cases that have a lower SOI/ROM than expected, based on their clinical complexity and acuity. It may also create a perception of bias or favoritism among physicians, if only some are selected for audit and education. C. Audit cases that have high SOI/ ROM assigned by coders for education and follow-up. This is not a reliable way to gain more information about the situation, because it may not reflect the true SOI/ROM levels of the cases, if there are errors or discrepancies in coding or grouping. It may also overlook the documentation improvement opportunities for cases that have low SOI/ROM assigned by coders, despite having high clinical complexity and acuity. References: CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 3MTM All Patient Refined Diagnosis Related Groups (APR DRGs) | 3M United States QandA: Understanding SOI and ROM in the APR-DRG system | ACDIS Use SOI/ROM scores to enhance CDI program effectiveness | ACDIS

• Question 29:

  Which of the following sources provide external benchmarks to examine the effectiveness of a facility's clinical documentation program?

  A. Health Care Financing Administration
  B. American Health Information Management Association
  C. Agency for Healthcare Research and Quality
  D. Medicare Provider Analysis and Review
  C. Agency for Healthcare Research and Quality

  ---

  Explanation/Reference:

  The Agency for Healthcare Research and Quality (AHRQ) provides external benchmarks to examine the effectiveness of a facility's clinical documentation program by developing and disseminating quality indicators (QIs) that measure various aspects of health care quality, such as patient safety, outcomes, efficiency, and effectiveness. These QIs are based on administrative data and can be used to compare the performance of different health care providers or facilities across the nation. The QIs include inpatient quality indicators (IQIs), patient safety indicators (PSIs), prevention quality indicators (PQIs), and pediatric quality indicators (PQIs). These QIs can help clinical documentation improvement (CDI) programs identify areas of improvement, monitor trends, and evaluate the impact of CDI interventions on health care quality 2. References: 1: Clinical Documentation Improvement Programs: Quality, Efficiency | Deloitte US Analysis 2 2: AHRQ Quality Indicators 3

• Question 30:

  A 70-year-old severely malnourished nursing home patient is admitted for a pressure ulcer covered by eschar on the right hip. The provider is queried to clarify the stage of the pressure ulcer. Because the wound has not been debrided, the provider responds "unable to determine". How will the stage of this pressure ulcer be coded?

  A. Stage IV pressure ulcer
  B. Stage III pressure ulcer
  C. Unstageable pressure ulcer
  D. Undetermined stage pressure ulcer
  C. Unstageable pressure ulcer

  ---

  Explanation/Reference:

  A pressure ulcer covered by eschar on the right hip is coded as an unstageable pressure ulcer, according to the ICD-10-CM Official Guidelines for Coding and Reporting. The guidelines state that "Pressure-induced deep tissue damage is defined as a pressure injury that is unstageable due to coverage of the wound bed by slough and/or eschar" 2. Eschar is a thick, dry, black necrotic tissue that obscures the depth of tissue loss and prevents accurate staging of the pressure ulcer 3. Therefore, the provider's response of "unable to determine" the stage of the pressure ulcer is consistent with the definition of unstageable pressure ulcer. The code for unstageable pressure ulcer of right hip is L89.210 4. References:

  1: AHIMA CDIP Exam Prep, Fourth Edition, p. 139 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section I.C.12.b.4 3: Pressure Ulcer/Injury Coding Pocket Guide - Centers for Medicare and Medicaid Services 2 4: ICD10-CM Code L89.210 - Pressure ulcer of right hip, unstageable : AHIMA CDIP Exam Prep, Fourth Edition : ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 : ICD-10-CM Code L89.210 - Pressure ulcer of right hip, unstageable : AHIMA CDIP Exam Prep, Fourth Edition : ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 : ICD-10-CM Code L89.210 - Pressure ulcer of right hip, unstageable : AHIMA CDIP Exam Prep, Fourth Edition https:// my.ahima.org/store/product?id=67077 : ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 https://www.cdc.gov/nchs/data/icd/10cmguidelines- FY2021.pdf : ICD-10-CM Code L89.210 - Pressure ulcer of right hip, unstageable https://www.icd10data.com/ICD10CM/Codes/L00-L99/L80-L99/L89-/L89.210