AHIMA CDIP Online Practice Questions and Exam Preparation

AHIMA CDIP Online Questions & Answers

• Question 41:

  Tracking denials within the clinical documentation integrity program is important to

  A. determine coding inaccuracies and educate as necessary
  B. file a timely appeal if the medical center disagrees with the RAC findings
  C. identify documentation improvement opportunities and educate as necessary
  D. confirm reimbursement was appropriate
  C. identify documentation improvement opportunities and educate as necessary

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  Explanation/Reference:

  Tracking denials within the clinical documentation integrity program is important to identify documentation improvement opportunities and educate as necessary because it helps to analyze the root causes of denials, improve the quality and specificity of clinical documentation, and reduce the risk of future denials. Denials can also provide feedback on the effectiveness of the CDI program and the areas that need more attention or intervention. (CDIP Exam Preparation Guide) References: CDIP Exam Content Outline1 CDIP Exam Preparation Guide2

• Question 42:

  The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?

  A. Expand use of coding queries by CDI team
  B. Add a physician advisor/champion to the CDI team
  C. Encourage physician-nurse cooperation
  D. Alter the physician documentation requirements
  B. Add a physician advisor/champion to the CDI team

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  Explanation/Reference:

  A strategy that should be part of a project aimed at improving the unacceptable documentation behaviors of some physicians is to add a physician advisor/champion to the CDI team. A physician advisor/champion is a physician leader who supports and advocates for the CDI program, educates and mentors other physicians on documentation best practices, resolves conflicts and barriers, and provides feedback and recognition to physicians who improve their documentation. A physician advisor/champion can help change the documentation behaviors of some physicians by using peer influence, credibility, and authority to motivate them to comply with the CDI program goals and standards. A physician advisor/ champion can also help bridge the gap between the CDI team and the physicians, and foster a culture of collaboration and quality improvement 23. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 136 4 2: The Role of Physician Advisors in Clinical Documentation Improvement Programs 5 3: Physician Advisor: The Key to Clinical Documentation Improvement Success

• Question 43:

  Which of the following is MOST likely to trigger a second-level review?

  A. A procedure code that increases reimbursement
  B. A diagnosis that impacts a quality-of-care measure
  C. An account coded before the discharge summary is available
  D. A record with multiple major complicating conditions (MCCs)
  D. A record with multiple major complicating conditions (MCCs)

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  Explanation/Reference:

  According to the AHIMA CDIP Exam Preparation Guide, a second-level review is a process that involves a review of coded records by a designated person or team to ensure the accuracy and completeness of coding and documentation1. A second-level review may be triggered by various factors, such as high-risk or high-dollar accounts, coding quality indicators, payer requirements, or internal audit findings1. One of the factors that is most likely to trigger a second-level review is a record with multiple major complicating conditions (MCCs)2. MCCs are diagnoses that significantly affect the severity of illness and resource utilization of a patient, and are assigned a higher relative weight in the DRG system3. A record with multiple MCCs may indicate a complex or unusual case that requires additional validation and verification of the coding and documentation. A record with multiple MCCs may also affect the reimbursement, risk adjustment, and quality scores of the hospital, and therefore may be subject to external scrutiny or audit4. The other options are not as likely to trigger a second-level review, as they are not as indicative of coding or documentation issues or risks. A procedure code that increases reimbursement may not necessarily require a second-level review, unless it is inconsistent with the documentation or the clinical indicators. A diagnosis that impacts a quality-of-care measure may be relevant for CDI purposes, but not necessarily for coding validation. An account coded before the discharge summary is available may be incomplete or inaccurate, but it may also be corrected or updated before final billing. References: CDIP Exam Preparation Guide - AHIMA Building a Resilient CDI: Second Level Review Major Complications or Comorbidities (MCC) and Complications or Comorbidities (CC) | CMS Demystifying and communicating case-mix index - ACDIS

• Question 44:

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

  A. October 1
  B. January 1
  C. July 1
  D. April 1
  A. October 1

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  Explanation/Reference:

  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

• Question 45:

  A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs: BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

  A. Query the physician to clarify if CXR result means patient has pneumonia.
  B. Query the physician to clarify for type of COPD such as severe asthma.
  C. Query the physician to clarify for clinical significance of the CXR results.
  D. Query the physician to clarify if patient has acute COPD exacerbation.
  A. Query the physician to clarify if CXR result means patient has pneumonia.

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  Explanation/Reference:

• Question 46:

  A clinical documentation integrity practitioner (CDIP) in an acute care hospital was asked to create new query templates for ICD-10 based on AHIMA and ACDIS guidelines. What should the multiple-choice query format include?

  A. Clinically insignificant options
  B. Impact on reimbursement
  C. Clinically unsupported diagnosis
  D. Clinically significant options
  D. Clinically significant options

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  Explanation/Reference:

• Question 47:

  What is the term used when a patient is entered in the Master Patient Index (MPI) multiple times, in different ways, resulting in multiple medical record numbers?

  A. Replica
  B. Clone
  C. Facsimile
  D. Overlap
  D. Overlap

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  Explanation/Reference:

  The term used when a patient is entered in the MPI multiple times, in different ways, resulting in multiple medical record numbers is overlap. An overlap occurs when a person has more than one medical record number within an integrated

  delivery network or enterprise, and may cause problems such as incomplete or inaccurate patient information, duplicate testing or treatment, billing errors, or patient safety issues. An overlap may be caused by data entry errors, system

  conversions, mergers or acquisitions, or lack of standardization. Regular audits of the MPI database must be done to identify and resolve any overlaps and ensure data quality and integrity.

  References:

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

  Master patient index - Clinfowiki1

• Question 48:

  A hospital noticed a 30% denial rate in Medicare claims due to lack of clinical documentation, placing the hospital at risk of multiple Medicare violations. What step should the clinical documentation integrity (CDI) manager take to help avoid future Medicare violations?

  A. Collaborate with physician advisor/champion and revenue cycle manager
  B. Instruct the billing department to write off claims with insufficient documentation
  C. Assign pre-billing claim review duties to physicians
  D. Prevent submission of claims for improper documentation
  A. Collaborate with physician advisor/champion and revenue cycle manager

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  Explanation/Reference:

  The step that the clinical documentation integrity (CDI) manager should take to help avoid future Medicare violations is to collaborate with physician advisor/champion and revenue cycle manager. The physician advisor/champion can help with educating and engaging the physicians on the importance and impact of clinical documentation on coding, reimbursement, quality measures, compliance, and patient care. The revenue cycle manager can help with analyzing and monitoring the denial trends and patterns, identifying and resolving the root causes of denials, implementing corrective actions and preventive measures, and ensuring timely and accurate claim submission and appeal processes. References: : https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf : https://my.ahima.org/store/product?id=67077

• Question 49:

  What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

  A. Multiple-choice
  B. Open-ended
  C. Verbal
  D. Yes/No
  D. Yes/No

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  Explanation/Reference:

  A yes/no query may not be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record because it may lead to leading or suggesting a diagnosis that is not supported by the provider's documentation. A yes/no query should only be used when there is clear and consistent documentation of a condition/diagnosis in the health record, and the query is seeking confirmation or denial of a specific fact or detail related to that condition/diagnosis. A multiple-choice, open-ended, or verbal query may be more appropriate to allow the provider to choose from a list of possible diagnoses, provide additional information, or explain the clinical reasoning behind the documentation. (CDIP Exam Preparation Guide) References: CDIP Exam Content Outline1 CDIP Exam Preparation Guide2 AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3

• Question 50:

  A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?

  A. No query is needed
  B. Query physician for POA
  C. Bring this case up in weekly Health Information Management meetings for further action
  D. Take the case to physician advisor/champion to discuss further action
  B. Query physician for POA

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  Explanation/Reference:

  A query should be generated to ask the physician for the POA indicator of the fall because the documentation is unclear whether the fall was present at the time of inpatient admission or not. The POA indicator is used to identify conditions that are present or not present at the time of admission, and has payment implications for certain hospital-acquired conditions (HACs). According to CMS, a fall resulting in trauma is one of the HACs that will not be paid at a higher rate if it is not present on admission. Therefore, it is important to clarify the POA indicator of the fall to ensure accurate coding and reimbursement. A query should be non-leading, concise, clear, relevant, and consistent with CDI standards and guidelines. References: CDIP?Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf) Coding | CMS1 Present on Admission Indicators - Novitas Solutions2