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NEW QUESTION # 65
Which of the following may result in an incomplete health record deficiency being assigned to a provider?
- A. A quality query
- B. An outstanding query
- C. A retrospective query
- D. A concurrent query
Answer: B
Explanation:
Explanation
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 :
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NEW QUESTION # 66
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. Bring this case up in weekly Health Information Management meetings for further action
- C. Take the case to physician advisor/champion to discuss further action
- D. Query physician for POA
Answer: D
Explanation:
Explanation
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
NEW QUESTION # 67
Which of the following diagnosis is MOST likely to trigger a second level review?
- A. Pneumonia
- B. Heart failure
- C. Acute kidney injury
- D. Malnutrition
Answer: D
Explanation:
Explanation
Malnutrition is a diagnosis that is most likely to trigger a second level review because it affects the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality measures of the hospital. Malnutrition also requires clinical validation and clear documentation of its etiology, type, degree, and duration2 References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 2:
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 68
Which of the following is considered a hospital-acquired condition if not present on admission?
- A. Diabetes with hypoglycemia
- B. Air leak
- C. Stage I and II pressure ulcers
- D. Blood incompatibility
Answer: D
Explanation:
Explanation
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
NEW QUESTION # 69
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. Adjusted case mix index
- C. Present on admission indicators
- D. Program for evaluating payment patterns electronic report
Answer: B
Explanation:
Explanation
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]
NEW QUESTION # 70
Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?
- A. CDI practitioner
- B. Chief Medical Officer
- C. Compliance Officer
- D. Chief Financial Officer
Answer: B
Explanation:
Explanation
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
NEW QUESTION # 71
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. Hire a consultant to communicate the benefits to the physicians
- B. Identify an influential physician advisor/champion to promote support
- C. Create a vision statement that outlines the project objectives
- D. Communicate the benefits of the CDI firm about the project
Answer: B
Explanation:
Explanation
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 Q&A: Defining roles for physician advisor/champion | ACDIS Q&A: 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
NEW QUESTION # 72
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 patient has acute COPD exacerbation.
- B. Query the physician to clarify for clinical significance of the CXR results.
- C. Query the physician to clarify if CXR result means patient has pneumonia.
- D. Query the physician to clarify for type of COPD such as severe asthma.
Answer: C
NEW QUESTION # 73
Which of the following should an organization consider when developing a query retention policy and procedure?
- A. What the escalation process will be
- B. Who should be queried
- C. If the query is considered part of the health record
- D. How the query will be formatted
Answer: C
Explanation:
Explanation
One of the factors that an organization should consider when developing a query retention policy and procedure is if the query is considered part of the health record or not. According to the AHIMA/ACDIS query practice brief1, a query is considered part of the health record if it meets any of the following criteria:
It is used to clarify documentation that affects code assignment or other data elements It is used to support clinical validation of a diagnosis or procedure It is used to support medical necessity or quality indicators It is used to communicate clinical information between providers If a query is part of the health record, it should be retained according to the organization's health record retention policy and procedure, which should comply with federal, state, and local laws and regulations. The query retention policy and procedure should also address issues such as:
The format and location of the query (e.g., paper, electronic, hybrid)
The security and confidentiality of the query
The accessibility and availability of the query
The ownership and custodianship of the query
The legal implications and evidentiary value of the query
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) Guidelines for Achieving a Compliant Query Practice-2022 Update1
NEW QUESTION # 74
The third quarter target concurrent physician query response rate for each physician in a hospital gastroenterology department was 80%. Nine physicians met or exceeded this metric; however, two physicians had third quarter concurrent physician query response rates of 19% and 64%. What is the best course of action for the clinical documentation integrity (CDI) physician advisor/champion?
- A. Schedule a group meeting with all physicians
- B. Schedule individual meetings with each low-performing physician
- C. Schedule a meeting with the chair of the gastroenterology department
- D. Schedule individual meetings with each physician
Answer: B
Explanation:
Explanation
According to the ACDIS Practice Brief, a query escalation policy should describe how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, the department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for the organization1. In this case, since two physicians have significantly lower query response rates than the target, the CDI physician advisor/champion should schedule individual meetings with each low-performing physician to provide feedback, education, and support. A group meeting with all physicians may not be effective or efficient, as it may not address the specific barriers or challenges faced by the low-performing physicians. A meeting with the chair of the gastroenterology department may be helpful, but it may not be sufficient to resolve the issue without direct communication with the low-performing physicians.
References:
CDI Week 2020 Q&A: CDI and key performance indicators1
NEW QUESTION # 75
The provider was queried because the patient met clinical criteria for acute hypoxic respiratory failure. The response to the query was different than what was expected by the clinical documentation integrity practitioner (CDIP). What should the CDIP do?
- A. Implement the department's escalation process
- B. Revise the query and send it back to the provider
- C. Have a different CDIP query the provider
- D. Record the query response as disagreed
Answer: A
Explanation:
Explanation
If the provider's response to the query is different than what was expected by the CDIP, the CDIP should implement the department's escalation process to ensure the validity and accuracy of the documentation and the coded data. The escalation process is a standardized procedure that involves a manager, committee, or other supervisory position to review and assess the query and the response, and to determine the appropriate next steps. The escalation process may include contacting the provider for clarification, education, or feedback; consulting with a physician advisor/champion or a coding auditor; or reporting the issue to a higher authority or regulatory body. The escalation process should be documented and communicated clearly and respectfully to all parties involved.
A: Record the query response as disagreed. This is not a sufficient action to take if the provider's response to the query is different than what was expected by the CDIP. Recording the query response as disagreed may indicate a lack of agreement or consensus between the CDIP and the provider, but it does not address the underlying issue of documentation validity or accuracy. It may also create a negative impression or relationship between the CDIP and the provider.
B: Have a different CDI query the provider. This is not an appropriate action to take if the provider's response to the query is different than what was expected by the CDIP. Having a different CDI query the provider may create confusion, inconsistency, or redundancy in the query process. It may also undermine the credibility or authority of the original CDI who queried the provider.
C: Revise the query and send it back to the provider. This is not a recommended action to take if the provider's response to the query is different than what was expected by the CDIP. Revising the query and sending it back to the provider may imply that the CDI is dissatisfied or disagreeing with the provider's response, which may be perceived as disrespectful or confrontational. It may also suggest that the CDI is trying to influence or coerce the provider to change their response, which may compromise the integrity and compliance of the query process.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Guidelines for Achieving a Compliant Query Practice-2022 Update | ACDIS Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA The Provider Query Toolkit: A Guide to Compliant Practices
NEW QUESTION # 76
Which of the following is a clinical documentation integrity (CDI) financial impact measure?
- A. Release of information
- B. Severity of illness
- C. Hierarchical condition category
- D. Case mix index
Answer: D
Explanation:
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 Q&A: CDI and key performance indicators1
Understanding CDI Metrics2
NEW QUESTION # 77
A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped. Which policy should the hospital follow to avoid a compliance risk?
- A. A post-bill query rarely occurs as a result of an audit or other internal monitor.
- B. A rebilling is permissible when queries are answered after the initial bill.
- C. A post bill query is not appropriate when an error is found after an audit.
- D. A second bill should not be submitted when the first bill was incomplete.
Answer: B
Explanation:
Explanation
A rebilling is permissible when queries are answered after the initial bill, as long as the hospital follows the appropriate guidelines and procedures for rebilling, such as submitting a corrected claim within the timely filing limit, notifying the payer of the reason for rebilling, and documenting the query process and outcome in the health record. Rebilling may be necessary to ensure accurate coding and reporting of the patient's condition and treatment, as well as appropriate reimbursement and quality measures. [3][3] References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf [3][3]:
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 78
An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are
- A. PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure - B. PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion - C. PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure - D. PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion
Answer: B
Explanation:
Explanation
According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023, the principal diagnosis is defined as "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"2. In this case, the patient was admitted with shortness of breath, productive yellow sputum, and a temperature of 101.2, which are signs and symptoms of pneumonia. The CXR confirmed the diagnosis of LLL pneumonia, which is a serious condition that requires inpatient care. Therefore, LLL pneumonia is the principal diagnosis.
The secondary diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay"2. In this case, the patient had bilateral pleural effusion and kidney failure at the time of admission, which are coexisting conditions that affect the treatment received and/or the length of stay. The renal consult documented AKI with ATN, which is a more specific diagnosis than kidney failure and reflects the severity and etiology of the condition. Therefore, AKI with ATN and bilateral pleural effusion are secondary diagnoses.
References:
CDI Week 2020 Q&A: CDI and key performance indicators1
ICD-10-CM Official Guidelines for Coding and Reporting FY 20232
NEW QUESTION # 79
A hospital is conducting a documentation integrity project for the purpose of reducing indiscriminate use of electronic copy and paste of patient information in records by physicians. Which data should be used to quantify the extent of the problem?
- A. Results of a survey of physicians that asks about documentation practices
- B. Percent of insurance billings denied due to lack of record documentation
- C. Incidence of redundancies in physician notes in a sample of hospital admissions
- D. Number of coder queries regarding inconsistent physician record documentation
Answer: C
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a documentation integrity project is a systematic process of identifying, analyzing, and improving the quality and accuracy of clinical documentation in the health record1. A documentation integrity project may have various purposes, such as enhancing patient safety, improving coding and reimbursement, or complying with regulatory standards1. One of the common issues that may affect the quality and accuracy of clinical documentation is the indiscriminate use of electronic copy and paste of patient information in records by physicians2. Copy and paste is a function that allows physicians to duplicate existing text in the record and paste it in a new destination, which may save time and effort, but also may introduce errors, inconsistencies, or redundancies in the documentation2. Therefore, to quantify the extent of the problem of copy and paste, the data that should be used is the incidence of redundancies in physician notes in a sample of hospital admissions. Redundancies are repeated or unnecessary information that may clutter the record and impair its readability and reliability3. By measuring the frequency and types of redundancies in physician notes, the hospital can assess the impact of copy and paste on the documentation quality and identify areas for improvement. The other options are not correct because they do not directly measure the problem of copy and paste. The percent of insurance billings denied due to lack of record documentation may reflect other issues besides copy and paste, such as incomplete or inaccurate documentation, coding errors, or payer policies4. The number of coder queries regarding inconsistent physician record documentation may indicate the presence of copy and paste, but it may also depend on other factors such as coder knowledge, query guidelines, or query response rate. The results of a survey of physicians that asks about documentation practices may provide some insight into the perceptions and attitudes of physicians regarding copy and paste, but it may not reflect the actual extent or impact of the problem on the documentation quality.
CDIP Exam Preparation Guide - AHIMA
Auditing Copy and Paste - AHIMA
Copy/Paste: Prevalence, Problems, and Best Practices - AHIMA
Documentation Denials: How to Avoid Them - AAPC
[Q&A: Querying for clinical validation | ACDIS]
NEW QUESTION # 80
A clinical documentation integrity (CDI) program that is compliant with regulations from the facility's payors results in
- A. higher overall program cost
- B. need for more CDI staff
- C. meeting external benchmarks
- D. less risk from audits
Answer: D
NEW QUESTION # 81
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?
- A. Expand the CDI program to larger areas in outpatient clinics
- B. Identify key metrics to develop program measures for coders
- C. Establish a CDI steering committee to build a strong foundation
- D. Prioritize to focus on efforts with the largest return on investment
Answer: C
Explanation:
Explanation
A CDI steering committee is a group of interdisciplinary leaders who oversee and guide the CDI program's objectives, outcomes, and metrics. The committee should include representatives from finance, clinical, coding, quality, and other areas that are impacted by CDI. The committee should meet regularly to review the CDI program's performance, identify opportunities for improvement, and provide support and education to the CDI staff and providers. A CDI steering committee can help reinvigorate a stagnant CDI program by ensuring that it aligns with the organization's vision and mission, addresses the current challenges and needs, and fosters collaboration and communication among stakeholders. The other options are not necessarily effective ways to reinvigorate a CDI program. Expanding the CDI program to larger areas in outpatient clinics may not be feasible or appropriate without a clear strategy and plan. Prioritizing to focus on efforts with the largest return on investment may not reflect the true value and quality of the CDI program. Identifying key metrics to develop program measures for coders may not capture the full scope and impact of the CDI program.
NEW QUESTION # 82
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