[Feb-2025] Practice AHIMA CDIP exam. Online Exam Practice Tests with detailed explanations! Pass CDIP with confidence! [Q60-Q82]

NEW QUESTION 60
Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include

performing data analysis

developing query forms

educating physicians

querying physicians

NEW QUESTION 61
Which of the following is nonessential to facilitate code capture when educating clinical staff on documentation practices associated with diabetes mellitus?

Type

Manifestation

Cause

Age

NEW QUESTION 62
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?
Collaborate with physician advisor/champion and revenue cycle manager
Instruct the billing department to write off claims with insufficient documentation

Assign pre-billing claim review duties to physicians

Prevent submission of claims for improper documentation

NEW QUESTION 63
A hospital administrator wants to initiate a clinical documentation integrity (CDI) program and has developed a steering committee to identify performance metrics. The CDI manager expects to use a case mix index as one of the metrics. Which other metric will need to be measured?

Comparison of risk of mortality with diagnostic related group capture rates

Assessment of APR-DRGs with capture of CC or MCC

Comparison of severity of illness with the CC capture rates

Assessment of CC/MCC capture rates

NEW QUESTION 64
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?

Physician and CDIP interaction

Coder and CDIP interaction

Executive oversight

Physician advisor/champion involvement

NEW QUESTION 65
Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

Neither of the codes can be assigned

Two codes can be used together to completely describe the condition

Only one code can be assigned to completely describe the condition

This is not a convention found in ICD-10-CM

NEW QUESTION 66
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?

Audit cases for missed diagnosis by the CDI practitioner to target in the education plan

Audit focused cases by physicians that have a higher SOI/ROM for education plan

Audit cases that have high SOI/ROM assigned by coders for education and follow-up

Audit focused APR-DRGs and develop education plan for CDI team and physicians

Explanation
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
3M™ All Patient Refined Diagnosis Related Groups (APR DRGs) | 3M United States Q&A: Understanding SOI and ROM in the APR-DRG system | ACDIS Use SOI/ROM scores to enhance CDI program effectiveness | ACDIS

NEW QUESTION 67
A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101° Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents “right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis”.
What is the proper sequencing of the principal and secondary diagnoses?

Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis

Right lower quadrant abdominal pain, fever, vomiting, leukocytosis

Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus

Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus

Explanation
The proper sequencing of the principal and secondary diagnoses in this case is as follows:
Principal diagnosis: Acute appendicitis. This is the condition, after study, that occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. The patient was admitted for laparoscopic surgery, which is a definitive treatment for acute appendicitis. The physician documented “possible acute appendicitis or probable Meckel diverticulitis” as the cause of the right lower quadrant abdominal pain. According to the AHA’s Coding Clinic, Fourth Quarter 2016, pp.
147-148, when a physician documents two diagnoses connected by “or”, coders should query the physician for clarification if possible. However, if a query is not possible or not answered, coders should assign codes for both conditions, unless one of them has been ruled out or confirmed by further testing or treatment. In this case, there is no indication that either acute appendicitis or Meckel diverticulitis has been ruled out or confirmed by further testing or treatment. Therefore, both conditions should be coded and reported. However, only one of them can be the principal diagnosis. Since acute appendicitis is more commonly associated with laparoscopic surgery than Meckel diverticulitis, and since it has a higher relative weight than Meckel diverticulitis under the MS-DRG system, it is reasonable to select acute appendicitis as the principal diagnosis 23.
Secondary diagnosis: Right lower quadrant abdominal pain. This is a sign or symptom that is associated with the principal diagnosis and requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. The patient presented with right lower quadrant abdominal pain as a manifestation of acute appendicitis or Meckel diverticulitis. The pain required clinical evaluation by abdominal ultrasound and therapeutic treatment by laparoscopic surgery. Therefore, it should be coded and reported as a secondary diagnosis 4.
Secondary diagnosis: Type I diabetes mellitus. This is a chronic condition that affects the patient’s care in terms of requiring diagnostic or therapeutic services or affecting patient outcomes or resource utilization. The patient has a history of type I diabetes mellitus and received an injection of neutral protamine Hagedorn insulin to normalize the blood sugar level prior to surgery. Therefore, it should be coded and reported as a secondary diagnosis 4.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section II.A 3: AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Fourth Quarter 2016 4: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section III.C : AHIMA CDIP Exam Prep, Fourth Edition https://my.ahima.org/store/product?id=67077

NEW QUESTION 68
Which of the following is a clinical documentation element supporting a transbronchial biopsy?

Length of procedure

Pathology report documenting alveolar tissue

Hemoptysis

Pathology report documenting bronchial tissue

NEW QUESTION 69
Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?

Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)

Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)

Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), Office of Inspector General (OIG)

Center for Improvement in Healthcare (CIHQ), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)

NEW QUESTION 70
Which of the following committees should determine the chain of comnfand that will be used to manage physicians who are either unresponsive or uncooperative with the clinical documentation integrity (CDI) program?

Oversight

Communications

Operations

Compliance

NEW QUESTION 71
The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate.
What might this indicate to the CDI manager?

The program is successful because documentation has improved

The loss of a large volume of patients has impacted workflow

CDI staff need education on identifying query opportunities

The decrease in hospital census has caused a lack of query opportunities

NEW QUESTION 72
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:

Authorship integrity

Patient identification and demographic accuracy

Documentation integrity

Auditing integrity

NEW QUESTION 73
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?

Stage IV pressure ulcer

Stage III pressure ulcer

Unstageable pressure ulcer

Undetermined stage pressure ulcer

NEW QUESTION 74
For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?

The name of the medication (aspirin), the date and time it was last administered

The name of the medication (aspirin), the date, time and location where it was last administered

The name of the medication (aspirin) and the date it was last administered

The name of the medication (aspirin), the date and location where it was last administered

NEW QUESTION 75
The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is

05HM33Z Insertion of infusion device into right internal jugular vein, percutaneous approach

02H633Z Insertion of infusion device into right atrium, percutaneous approach

05HP33Z Insertion of infusion device into right external jugular vein, percutaneous approach

02HV33Z Insertion of infusion device into superior vena cava, percutaneous approach

NEW QUESTION 76
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?

Expand the CDI program to larger areas in outpatient clinics

Prioritize to focus on efforts with the largest return on investment

Identify key metrics to develop program measures for coders

Establish a CDI steering committee to build a strong foundation

NEW QUESTION 77
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?

Hospital acquired conditions

Program for evaluating payment patterns electronic report

Present on admission indicators

Adjusted case mix index

NEW QUESTION 78
The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?

Update medical records with unsigned physician responses

Allow physician responses via e-mail

Provide education to physicians on query process

Require the CDIP to call physicians to follow up

NEW QUESTION 79
Which of the following should be examined when developing documentation integrity projects?

Query rates from coding staff

CC and MCC capture rates

Coding productivity statistics

Physician satisfaction surveys

NEW QUESTION 80
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?

Determine primary interests and needs as requested

Determine primary interests of an individual or department

Teach coding classes to the new physicians as needed

Teach nursing staff about documentation integrity

NEW QUESTION 81
The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to

provide community education to healthcare consumers

create synergy between clinical education and CDI principles

show a direct relationship between clinical documentation and quality patient care

promote CDI functions so that physicians view the CDI staff as value-added service

NEW QUESTION 82
A noncompliant query includes querying the provider regarding

acute blood loss anemia due to low hemoglobin treated with iron supplements

sepsis that was present on admission because sepsis was only documented in the discharge summary

gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators

morbid obesity due to BMI of 40.9 documented on the history and physical

[Feb-2025] Practice AHIMA CDIP exam. Online Exam Practice Tests with detailed explanations! Pass CDIP with confidence! [Q60-Q82]

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