[Apr 11, 2024] CDIP Free Exam Questions with Quality Guaranteed
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NEW QUESTION # 38
A clinical documentation integrity practitioner (CDIP) is looking for clarity on whether a diagnosis has been
"ruled in" or "ruled out". Which type of query is the best option?
- A. Yes/No
- B. None
- C. Open-ended
- D. Multiple-choice
Answer: C
Explanation:
Explanation
An open-ended query is a type of query that allows the provider to respond with free text, rather than choosing from a list of options or answering yes or no. An open-ended query is appropriate when the CDIP is looking for clarity on whether a diagnosis has been "ruled in" or "ruled out", because it allows the provider to document the final diagnosis or impression based on the clinical evidence and reasoning. An open-ended query also avoids leading or suggesting a specific diagnosis to the provider, which could compromise the integrity and validity of the documentation. (Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1) References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1
NEW QUESTION # 39
A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate
- A. aftercare
- B. initial
- C. subsequent
- D. sequela
Answer: A
Explanation:
Explanation
The ICD-10-CM 7th character code value should indicate aftercare for a patient who falls off a ladder and undergoes a right femur procedure, and then returns to the hospital for removal of the external fixation device.
Aftercare codes are used to capture encounters for follow-up care after completed treatment of an injury or condition, such as removal of external fixation devices, casts, or pins. Aftercare codes are not used for subsequent encounters for complications or infections related to the injury or condition5 References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 5:
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 40
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 for clinical significance of the CXR results.
- B. Query the physician to clarify if patient has acute COPD exacerbation.
- 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 # 41
Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?
- A. Value and mission statements
- B. Diagnostic related groups and revenue cycle
- C. Reporting and the use of technology
- D. Benchmarks and case mix index
Answer: A
Explanation:
Explanation
A CDI program's vision should reflect its purpose, values, and goals, and align with the organization's overall vision and mission. Value and mission statements help define the CDI program's role, scope, and objectives, and communicate them to stakeholders. Reporting and the use of technology are important tools for a CDI program, but they are not part of its vision. Benchmarks and case mix index are performance indicators that measure the CDI program's outcomes, but they do not reflect its vision. Diagnostic related groups and revenue cycle are aspects of reimbursement that may be affected by the CDI program, but they are not the primary focus of its vision.
NEW QUESTION # 42
Hospital policy states that physician responses to queries should be no longer than timely payer filing requirements. A physician responds to a query after the final bill has been submitted. How should administration respond in this situation?
- A. Evaluate the payer's timeframe for billing and reasons for the physician's delayed response
- B. Review the record to determine any potential data integrity impact and/or rebilling implications
- C. Maintain the original billing as supported by documentation in the medical record
- D. Report the physician's delayed response to the Ethics and Compliance Committee
Answer: B
Explanation:
Explanation
Administration should respond to this situation by reviewing the record to determine any potential data integrity impact and/or rebilling implications. According to the AHIMA Practice Brief on Managing an Effective Query Process, post-bill queries are generally initiated as a result of an audit or other internal monitor, and healthcare entities can develop a policy regarding whether they will generate post-bill queries and the timeframe following claims generation that queries may be initiated. The practice brief also states that healthcare entities should consider the following three concepts in the development of a post-bill (including query) policy: applying normal course of business guidelines, using payer-specific rules on rebilling timeframes, and determining reliability of query response over time 2. Therefore, administration should review the record to see if the physician's response to the query affects the quality of care, patient safety, severity of illness, risk of mortality, or reimbursement, and if so, whether it is appropriate and feasible to rebill the account based on the payer's rules and the normal course of business guidelines. Administration should also evaluate the reasons for the physician's delayed response and provide feedback and education to prevent future occurrences.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: AHIMA Practice Brief: Managing an Effective Query Process 4
NEW QUESTION # 43
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. Severity of illness
- B. Case mix index
- C. Risk of mortality
- D. Outcome measures
Answer: D
Explanation:
Explanation
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 Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) CDIP Exam Preparation Guide (https://my.ahima.org/store/product?id=67077)
NEW QUESTION # 44
A key physician approaches the director of the coding department about the new emphasis associated with clinical documentation integrity (CDI). The physician does not support the program and believes the initiative will encourage inappropriate billing.
How should the director respond to the concerns?
- A. Refer the physician to the finance department to discuss required billing changes
- B. Inform the physician that changes must be made
- C. Develop an administrative panel to oversee CDI process
- D. Involve the physician advisor/champion in addressing the medical staff's concerns
Answer: D
Explanation:
Explanation
The director should involve the physician advisor/champion in addressing the medical staff's concerns because the physician advisor/champion is a key member of the CDI team who can provide clinical expertise, education, and leadership to promote CDI among physicians. The physician advisor/champion can help to explain the goals and benefits of CDI, such as improving patient care quality, accuracy of documentation, and appropriate reimbursement. The physician advisor/champion can also address any misconceptions or fears that the physicians may have about CDI, such as encouraging inappropriate billing or increasing their workload.
The physician advisor/champion can serve as a liaison between the CDI team and the medical staff, and foster a culture of collaboration and trust.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) CDIP Exam Preparation Guide (https://my.ahima.org/store/product?id=67077)
NEW QUESTION # 45
A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?
- A. Review the history and physical
- B. Query the attending provider
- C. Look for wound care documentation
- D. Read the nursing admission notes
Answer: A
Explanation:
Explanation
The first step that a clinical documentation integrity practitioner (CDIP) should take to determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary is to review the history and physical (H&P) because it is the initial source of information about the patient's condition at the time of admission. The H&P should include a comprehensive physical examination that covers all body systems, including the skin. If the H&P documents the presence of a stage IV sacral decubitus ulcer, then the POA status is "yes". If the H&P does not mention the ulcer, then the CDIP should look for other sources of documentation, such as wound care notes, nursing notes, or progress notes, to see if the ulcer was identified or treated during the hospital stay. If there is no clear evidence of when the ulcer developed, then the CDIP should query the attending provider to clarify the POA status. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Present on Admission Reporting Guidelines3
NEW QUESTION # 46
Which of the following individuals is the first line of escalation for an unanswered query?
- A. CDI Manager
- B. HIM/Coding Manager
- C. Medical Director
- D. CDI Steering Committee
Answer: A
Explanation:
Explanation
The first line of escalation for an unanswered query is the CDI Manager because they are responsible for overseeing the CDI program and ensuring compliance with query policies and procedures. The CDI Manager can monitor the query response rates, identify the providers who are not responding, and communicate with them to address any issues or barriers. The CDI Manager can also provide education and feedback to the providers on the importance and benefits of timely query responses. If the CDI Manager is unable to resolve the problem, then they can escalate it to the next level, such as the Medical Director or the CDI Steering Committee. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Q&A: Establishing an escalation policy for inappropriate queries3
NEW QUESTION # 47
A 75-year-old, diabetic patient with a history of osteoporosis, being treated with Fosamax, who sustained a femur fracture after falling down three stairs. The provider's documentation indicates to admit the patient for a traumatic femur fracture and an orthopedics consult is pending. The clinical documentation integrity practitioner (CDIP) decides to query for a possible link between osteoporosis and the femur fracture. Which of the following is the most compliant query based on the most recent AHIMA/ACDIS query practice brief?
- A. Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Could diabetes be a contributing factor in the femur fracture?
- B. Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. In your medical opinion, is this fracture consistent with an osteoporotic pathological fracture?
- C. Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please clarify the cause of the femur fracture in your next note and/or the discharge summary.
- D. Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please document "femur fracture due to osteoporosis" in your next progress note to demonstrate a link between the two diagnoses.
Answer: B
Explanation:
Explanation
This query option is the most compliant based on the most recent AHIMA/ACDIS query practice brief because it meets the following criteria:
It is based on clinical indicators in the health record that support a reasonable and logical connection between the conditions (femur fracture and osteoporosis).
It is non-leading and non-suggestive, as it does not imply a specific answer or diagnosis, but rather asks for the provider's opinion based on their clinical judgment.
It is concise and clear, as it uses simple and direct language that avoids ambiguity or confusion.
It is relevant and specific, as it addresses a clinical issue that has an impact on patient care, quality reporting, and/or reimbursement.
It is consistent with clinical documentation integrity (CDI) standards and guidelines, as it follows the AHIMA/ACDIS query practice brief recommendations for query format, content, delivery, and documentation.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) CDIP Exam Preparation Guide (https://my.ahima.org/store/product?id=67077) Guidelines for Achieving a Compliant Query Practice-2022 Update (https://acdis.org/resources/guidelines-achieving-compliant-query-practice%E2%80%942022-update)
NEW QUESTION # 48
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. Program for evaluating payment patterns electronic report
- B. Present on admission indicators
- C. Hospital acquired conditions
- D. Adjusted case mix index
Answer: D
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 # 49
Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?
- A. Compliance Officer
- B. CDI practitioner
- C. Chief Medical Officer
- D. Chief Financial Officer
Answer: C
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 # 50
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. Clinically significant options
- C. Impact on reimbursement
- D. Clinically unsupported diagnosis
Answer: B
NEW QUESTION # 51
An 86-year-old female is brought to the emergency department by her daughter. The patient complains of feeling tired, weak and excessive sleeping. The patient's daughter comments that patient's mental condition has not been the same. Lab results are unremarkable except for a sodium level of 119, a BUN of 22, and a creatinine of 1.35. The patient receives normal saline IV infusing at 100 cc/hr. The admitting diagnosis is weakness, altered mental status and dehydration. Which of the following queries is presented in an ethical manner thus avoiding potential fraud and/or compliance issues?
- A. Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr. Is the altered mental status related to the sodium of 119?
- B. Patient's sodium is 119 and she is on NS IV at 100 cc/hr, does patient have hyponatremia?
- C. Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr, please clarify the clinical significance of the lab result.
- D. Patient's sodium is 119 and she is on NS IV at 100 cc/hr, is this clinically significant? If so, please document a corresponding diagnosis related to this lab result.
Answer: C
NEW QUESTION # 52
Which of the following is considered a hospital-acquired condition if not present on admission?
- A. Stage I and II pressure ulcers
- B. Blood incompatibility
- C. Air leak
- D. Diabetes with hypoglycemia
Answer: B
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 # 53
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Q&As with Explanations Verified & Correct Answers: https://www.trainingquiz.com/CDIP-practice-quiz.html
Practice Exams and Training Solutions for Certifications: https://drive.google.com/open?id=10IozV1wDVZ2SmAOBjLWe3EM0W_sixFgK
