AHIMA AHIMA Certifications CDIP Questions & Answers

• Question 71:

  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.

  Correct Answer: A

• Question 72:

  While reviewing a chart, a clinical documentation integrity practitioner (CDIP) needs to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes 1 and 2. Which coding reference should be used?

  A. Faye Brown's Coding Handbook

  B. AMA CPT Assistant

  C. ICD-10-CM Official Guidelines for Coding and Reporting

  D. AHA Coding Clinic for ICD-10-CM

  Correct Answer: C

  The coding reference that should be used to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes 1 and 2 is the ICD-10-CM Official Guidelines for Coding and Reporting. This document provides the conventions and instructions for the proper use of the ICD-10-CM classification system, including the definitions and examples of the Includes Notes and Excludes Notes 1 and 2. The document is updated annually by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), and is available online at 2. The other coding references listed are not specific to ICD-10-CM or do not contain the general rules for the Includes Notes and Excludes Notes 1 and 2. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 4

• Question 73:

  A hospital administrator has hired a clinical documentation integrity (CDI) firm to improve its revenue objectives. The physicians object to this action. How should the firm collaborate with physicians to overcome their objections?

  A. Create a vision statement that outlines the project objectives

  B. Communicate the benefits of the CDI firm about the project

  C. Hire a consultant to communicate the benefits to the physicians

  D. Identify an influential physician advisor/champion to promote support

  Correct Answer: D

  A physician advisor/champion is a physician leader who supports and advocates for the CDI program and its objectives. A physician advisor/champion can help overcome the objections of other physicians by providing education, feedback, guidance, and mentorship on documentation best practices and their impact on revenue, quality, and patient care. A physician advisor/champion can also act as a liaison between the CDI firm and the medical staff, resolve conflicts or discrepancies in documentation, and foster a culture of collaboration and improvement. Physicians are more likely to trust and engage with their peers who understand their clinical perspective and challenges, rather than an external CDI firm that may be perceived as intrusive or disruptive. A. Create a vision statement that outlines the project objectives. This is not sufficient to collaborate with physicians and overcome their objections. A vision statement is a general statement that describes the desired outcome of the project, but it does not address the specific concerns or questions that physicians may have about the CDI firm's role, methods, or benefits.

  B. Communicate the benefits of the CDI firm about the project. This is not enough to collaborate with physicians and overcome their objections. Communicating the benefits of the CDI firm may be informative, but it may not be persuasive or credible if it comes from the CDI firm itself, without any endorsement or support from a physician leader within the organization.

  C. Hire a consultant to communicate the benefits to the physicians. This is not a good way to collaborate with physicians and overcome their objections. Hiring a consultant may add another layer of complexity and cost to the project, and it may not improve the trust or relationship between the CDI firm and the physicians. A consultant may also lack the clinical expertise or authority to influence the physicians' behavior or attitude. 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 74:

  A patient presents to the emergency room with acute shortness of breath. The patient has a history of lung cancer that has been treated previously with radiation and chemotherapy. The patient is intubated and placed on mechanical ventilation. A chest x-ray is remarkable for a pleural effusion. A thoracentesis is performed, and the cytology results show malignant cells. Diagnoses on discharge: Acute respiratory failure due to recurrence of small cell carcinoma and malignant pleural effusion. Which coding reference takes precedence for assigning the ICD-10-CM/PCS codes?

  A. Conventions and instructions of the classification for ICD-10-CM/PCS

  B. AMA CPT Assistant

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

  D. ICD-10-CM Official Guidelines for Coding and Reporting

  Correct Answer: A

  According to the CDIP?ontent Outline, one of the tasks of a clinical documentation integrity practitioner (CDIP) is to apply coding conventions, guidelines, and definitions for ICD-10-CM/PCS. Coding conventions are the general rules for the use of the classification system, such as the use of abbreviations, punctuation, symbols, and sequencing instructions. Coding guidelines are the official rules for selecting and reporting codes based on the documentation in the health record. Coding definitions are the explanations of the terms and concepts used in the classification system. The conventions and instructions of the classification for ICD-10-CM/PCS take precedence over any other coding reference because they are the primary source of coding rules and standards. The other coding references, such as AMA CPT Assistant, AHA Coding Clinic for ICD-10-CM/PCS, and ICD- 10-CM Official Guidelines for Coding and Reporting, are secondary sources that provide additional guidance, clarification, or interpretation of the coding conventions and instructions. References: CDIP?ontent Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf) ICD-10-CM Features | Diagnosis Coding: Using the ICD-10-CM1

• Question 75:

  Which of the following is considered a hospital-acquired condition if not present on admission?

  A. Air leak

  B. Diabetes with hypoglycemia

  C. Stage I and II pressure ulcers

  D. Blood incompatibility

  Correct Answer: D

  Blood incompatibility is considered a hospital-acquired condition if not present on admission, according to the CMS Hospital-Acquired Conditions (HAC) Reduction Program. This program reduces payments to hospitals that have high rates of certain conditions that are acquired during the hospital stay and could have been prevented by following evidence-based guidelines. Blood incompatibility is one of the 14 HAC categories that are included in the program, and it refers to a patient receiving a blood transfusion with incompatible blood type or Rh factor, which can cause serious adverse reactions such as hemolysis, anemia, renal failure, or death 23. Blood incompatibility is a preventable condition that can be avoided by proper blood typing and cross-matching before transfusion, and by following strict protocols and procedures for blood handling and administration 4. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 5 2: Hospital-Acquired Conditions | CMS 1 3: Hospital Acquired Conditions (HACs) - New York State Department of Health 3 4: Transfusion Reactions - Hematology and Oncology - Merck Manuals Professional Edition 6

• Question 76:

  When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?

  A. Physician and CDIP interaction

  B. Coder and CDIP interaction

  C. Executive oversight

  D. Physician advisor/champion involvement

  Correct Answer: B

  According to the AHIMA/ACDIS Query Practice Brief, one of the fundamental elements that must be in place for a successful DRG discrepancy resolution is a collaborative and respectful interaction between the coder and the CDIP1. The coder and the CDIP should communicate effectively and timely to identify and resolve any DRG mismatches, using evidence-based guidelines, coding conventions, and query standards1. The coder and the CDIP should also share their knowledge and expertise with each other, and seek clarification from the provider or the physician advisor/champion when necessary1. The other options are not considered fundamental elements for DRG discrepancy resolution, although they may be helpful or supportive in some situations. References: Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

• Question 77:

  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

  Correct Answer: C

  Explanation: 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 78:

  A clinical documentation integrity practitioner (CDIP) is developing a plan to promote the CDI program throughout a major hospital. It is proving challenging to find support. What is a primary step for the CDIP?

  A. Determine primary interests and needs as requested

  B. Determine primary interests of an individual or department

  C. Teach coding classes to the new physicians as needed

  D. Teach nursing staff about documentation integrity

  Correct Answer: B

  A primary step for the CDIP to promote the CDI program throughout a major hospital is to determine the primary interests of an individual or department that could benefit from or support the CDI program. This is because different stakeholders may have different motivations, expectations, and challenges related to CDI, and the CDIP should tailor the communication and education strategies accordingly. For example, physicians may be interested in how CDI can improve their quality metrics, reimbursement, and patient outcomes; coders may be interested in how CDI can reduce coding errors, denials, and queries; and executives may be interested in how CDI can enhance revenue integrity, compliance, and reputation. By identifying the primary interests of each individual or department, the CDIP can demonstrate the value and relevance of the CDI program, address any barriers or concerns, and foster collaboration and engagement 23. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: How to Promote Your Clinical Documentation Improvement Program 3: How to Market Your Clinical Documentation Improvement Program

• Question 79:

  Which of the following falls under the False Claims Act?

  A. Missing charges

  B. Unbundling services

  C. Missing modifiers

  D. Missing diagnosis codes

  Correct Answer: B

  Unbundling services falls under the False Claims Act because it is a form of coding fraud that involves billing separately for components of a related group of procedures or tests that should be billed as a single code. For example, if a provider performs a comprehensive metabolic panel, which is a blood test that measures several components of the blood, such as glucose, electrolytes, and liver enzymes, and bills for each component individually instead of using the single code for the panel, that is unbundling. Unbundling services can result in overpayment by the government and can violate the False Claims Act, which prohibits submitting false or fraudulent claims for payment to the government, including the Medicare and Medicaid programs. Violators of the False Claims Act can face civil penalties of up to three times the amount of the false claim plus an additional $11,000 per claim 23. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: Coding Fraud | VSG 5 3: False Claims Act | OIG 2

• Question 80:

  The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

  A. look for documented conditions that have well supported accompanying clinical criteria

  B. determine if only the treatment is documented and there is no diagnosis documented

  C. watch for reportable conditions or conditions that are unambiguous or otherwise complete

  D. identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis

  Correct Answer: B