AHIMA AHIMA Certifications CDIP Questions & Answers

• Question 31:

  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

  Correct Answer: B

  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 32:

  Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?

  A. No query is needed because the patient was dehydrated

  B. Query the physician to see if acute renal failure is clinically supported

  C. Query the physician to see if acute renal failure with tubular necrosis is supported

  D. Code acute renal failure since symptoms are there and documented

  Correct Answer: B

  The appropriate action in this case is to query the physician to see if acute renal failure is clinically supported. This is because the patient has signs and symptoms of acute renal failure, such as oliguria, pulmonary edema, and elevated creatinine, but the diagnosis is not documented in the medical record. Acute renal failure is a clinical syndrome characterized by a rapid decline in kidney function and accumulation of metabolic waste products. It can be caused by various factors, such as dehydration, hypovolemia, sepsis, nephrotoxins, or obstruction. Acute renal failure can be classified according to the RIFLE criteria (Risk, Injury, Failure, Loss, End-stage kidney disease) or the AKIN criteria (Acute Kidney Injury Network), which are based on changes in serum creatinine and urine output 23. A query to the physician is needed to confirm or rule out the diagnosis of acute renal failure, specify the etiology and severity of the condition, and document any associated complications or comorbidities. A query to the physician will also improve the accuracy and completeness of the documentation and coding, and reflect the true clinical picture and resource utilization of the patient. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: Acute Kidney Injury: Diagnosis and Management | AAFP 3: AKIN Classification for Acute Kidney Injury (AKI) - MDCalc

• Question 33:

  An increase in claim denials has prompted a clinical documentation integrity (CDI) manager to engage the CDI physician advisor/champion in an effort to avoid future denials. How does this strategy impact the goal?

  A. The CDI manager will exclusively provide education.

  B. Physicians will learn documentation integrity practices from peers.

  C. Physicians can manage the documentation integrity process.

  D. Clinicians will not require documentation integrity education.

  Correct Answer: B

  Engaging the CDI physician advisor/champion in an effort to avoid future denials is a strategy that impacts the goal of improving documentation integrity by leveraging the influence and expertise of a physician leader who can educate, mentor, and advocate for other physicians on documentation best practices. The CDI physician advisor/champion can act as a liaison between the CDI team and the medical staff, provide feedback and guidance on complex or challenging cases, resolve conflicts or discrepancies in documentation, and promote a culture of collaboration and quality improvement. Physicians are more likely to learn and adopt documentation integrity practices from their peers who understand their clinical perspective and challenges, rather than from non-physician CDI staff or managers.

  A. The CDI manager will exclusively provide education. This is incorrect because engaging the CDI physician advisor/champion implies that the CDI manager will not be the sole source of education, but rather will partner with the physician leader to deliver effective and tailored education to the medical staff.

  C. Physicians can manage the documentation integrity process. This is incorrect because engaging the CDI physician advisor/champion does not mean that physicians will take over the responsibility of managing the documentation integrity process, which involves multiple stakeholders, such as CDI specialists, coders, quality analysts, and auditors. Rather, physicians will be more involved and supportive of the documentation integrity process as a result of the education and mentorship provided by the CDI physician advisor/champion. D. Clinicians will not require documentation integrity education. This is incorrect because engaging the CDI physician advisor/champion does not eliminate the need for documentation integrity education for clinicians, but rather enhances and facilitates it by using a peer-to-peer approach that can increase awareness, engagement, and compliance among physicians. References: CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 QandA: Defining roles for physician advisor/champion | ACDIS QandA: The Role of the Physician Advisor in CDI | ACDIS The Role of a Physician Advisor - UASI Solutions PA/NP in Physician Champion / Advisor Role -- ACDIS Forums

• Question 34:

  A modifier may be used in CPT and/or HCPCS codes to indicate

  A. a service or procedure was increased or reduced

  B. a service or procedure was performed in its entirety

  C. a service or procedure resulted in expected outcomes

  D. a service or procedure was performed by one provider

  Correct Answer: A

  According to the AHIMA CDIP Exam Preparation Guide, a modifier is a two-digit numeric or alphanumeric code that may be used in CPT and/or HCPCS codes to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code1. One of the reasons to use a modifier is to indicate that a service or procedure was increased or reduced in comparison to the usual service or procedure2. For example, modifier 22 can be used to report increased procedural services that require substantially greater time, effort, or complexity than the typical service3. The other options are not correct because they do not reflect the purpose of using modifiers. A service or procedure performed in its entirety does not need a modifier, as it is assumed to be the standard service or procedure. A service or procedure resulting in expected outcomes does not affect the coding or reimbursement of the service or procedure. A service or procedure performed by one provider may need a modifier depending on the type of provider, the place of service, and the payer rules, but it is not a general reason to use a modifier. References: CDIP Exam Preparation Guide - AHIMA Modifiers: A Guide for Health Care Professionals - CMS CPT?Modifiers: 22 Increased Procedural Services | AAPC

• Question 35:

  Which of the following indicates a noncompliant multiple-choice query? One that does NOT

  A. include at least four options

  B. allow the provider to add their own response

  C. list options in alphabetical order

  D. include the option of "unable to determine"

  Correct Answer: A

  A noncompliant multiple-choice query is one that does not include at least four options because it may limit the provider's choice and suggest a preferred answer. A compliant multiple-choice query should include at least four options that are clinically significant, reasonable, and plausible based on the clinical indicators and documentation in the health record. The options should also be listed in alphabetical order to avoid any bias or preference. A compliant multiple-choice query should also allow the provider to add their own response if none of the options are appropriate, and include the option of "unable to determine" if the provider cannot make a definitive diagnosis based on the available information. (CDIP Exam Preparation Guide) References: CDIP ontent Outline1 CDIP Exam Preparation Guide2 Guidelines for Achieving a Compliant Query Practice (2019 Update)3

• Question 36:

  A query should be generated when documentation contains a

  A. postoperative hospital-acquired condition

  B. principal diagnosis without an MCC

  C. diagnosis without clinical validation

  D. problem list with symptoms related to the chief complaint

  Correct Answer: C

  A query should be generated when documentation contains a diagnosis without clinical validation, meaning that there is no evidence in the health record to support the diagnosis or that the diagnosis is inconsistent with other clinical

  indicators. A diagnosis without clinical validation may affect the accuracy and completeness of coding, quality measures, reimbursement, and patient care.

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

• Question 37:

  Which of the following may result in an incomplete health record deficiency being assigned to a provider?

  A. A quality query

  B. A retrospective query

  C. A concurrent query

  D. An outstanding query

  Correct Answer: D

  An outstanding query may result in an incomplete health record deficiency being assigned to a provider, if the query is not answered or resolved before the discharge or final coding of the patient. An outstanding query is a query that has been generated by the clinical documentation integrity practitioner (CDIP) or the coder, but has not been acknowledged or addressed by the provider. An outstanding query may affect the accuracy and completeness of the health record, as well as the coding, reimbursement, quality measures, and compliance of the hospital. References: : https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf : https://my.ahima.org/store/product?id=67077

• Question 38:

  Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program?

  A. Hospital acquired conditions

  B. Program for evaluating payment patterns electronic report

  C. Present on admission indicators

  D. Adjusted case mix index

  Correct Answer: D

  According to the AHIMA CDIP Exam Preparation Guide, the adjusted case mix index (CMI) is a measure that demonstrates the relative severity and complexity of patients treated in a hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program1. The adjusted CMI is calculated by multiplying the unadjusted CMI by a factor that accounts for the percentage of Medicare patients in the hospital2. The higher the adjusted CMI, the higher the expected reimbursement per patient, and the more effective the CDI program is assumed to be3. The other options are not correct because they do not measure the severity and complexity of patients or the financial impact of CDI. Hospital acquired conditions (HACs) are conditions that are not present on admission and are considered preventable by CMS, and may result in reduced reimbursement or penalties4. The program for evaluating payment patterns electronic report (PEPPER) is a report that provides hospital-specific data on potential overpayments or underpayments for certain services or diagnoses, and helps identify areas of risk or opportunity for improvement. Present on admission (POA) indicators are codes that indicate whether a condition was present at the time of admission or acquired during the hospital stay, and affect the assignment of DRGs and HACs. References: CDIP Exam Preparation Guide - AHIMA Demystifying and communicating case-mix index - ACDIS What is Case Mix Index? | The Importance of CMI Hospital-Acquired Conditions (HACs) | CMS [PEPPER Resources] [Present on Admission Reporting Guidelines - CMS]

• Question 39:

  Which of the following is used to measure the impact of a clinical documentation integrity (CDI) program on Centers for Medicare and Medicaid Services quality performance?

  A. Risk of mortality

  B. Case mix index

  C. Severity of illness

  D. Outcome measures

  Correct Answer: D

  Outcome measures are indicators of the quality of care provided by a healthcare organization, such as mortality rates, readmission rates, hospital-acquired conditions, patient safety indicators, and patient satisfaction scores. These measures are used by CMS to evaluate and compare the performance of hospitals and other providers under various pay-for-performance programs, such as value-based purchasing, hospital readmissions reduction program, hospital-acquired

  condition reduction program, and hospital inpatient quality reporting program. A CDI program can influence these outcome measures by ensuring that the clinical documentation accurately reflects the severity of illness, risk of mortality, and

  complexity of care of the patients. This can help to improve the risk adjustment and case mix index of the organization, as well as to identify and prevent potential quality issues.

  References:

  CDIP?ontent Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf)

  CDIP?Exam Preparation Guide (https://my.ahima.org/store/product?id=67077)

• Question 40:

  What type of laboratory test is a creatinine test?

  A. Chemistry

  B. Microbiology

  C. Hematology

  D. Serology

  Correct Answer: A