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Latest Updated AHIMA CDIP Exams Training: Certified Documentation Integrity Practitioner & Exam CDIP Questions

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Exam CDIP Questions | CDIP Exam Format

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AHIMA Certified Documentation Integrity Practitioner Sample Questions (Q115-Q120):

NEW QUESTION # 115
The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?

A. Have CDI manager teaming with coding supervisor to monitor physician responses
B. Require physicians to document responses in charts
C. Permit CDI practitioners to document physician responses in the charts
D. Allow physician to respond via e-mail

Answer: B

Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, one of the best practices for a compliant query process is to require physicians to document their responses to queries in the health record1. This ensures that the documentation is consistent, accurate, and complete, and that the query and response are part of the permanent record. Verbal responses are not acceptable, as they do not provide a clear audit trail and may lead to errors or discrepancies in coding and billing1. Therefore, the CDI manager should educate the physicians on the importance of documenting their responses in the charts and monitor their compliance. The other options are not recommended, as they may compromise the integrity of the documentation or violate the query guidelines1. References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

NEW QUESTION # 116
A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

A. query the provider to see if respiratory insufficiency is supported by the health record
B. query the provider to see if chronic respiratory failure is supported by the health record
C. code the diagnoses of COPD exacerbation and chronic respiratory failure
D. query the provider to see if acute on chronic respiratory failure is supported by the health record

Answer: D

Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, one of the scenarios that warrants a query is when there is clinical evidence of a higher degree of specificity or severity1. In this case, the patient's COPD exacerbation and oxygen therapy may indicate a higher level of respiratory impairment than chronic respiratory failure alone. Therefore, a query to the provider to see if acute on chronic respiratory failure is supported by the health record is appropriate and compliant. Acute on chronic respiratory failure is a more specific and severe diagnosis that may affect the patient's severity of illness, risk of mortality, and reimbursement2. The other options are not correct because they either assume a diagnosis without querying the provider, or query for a less specific or severe diagnosis than what the clinical indicators suggest.
References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Q&A: Respiratory failure in a drug overdose | ACDIS

NEW QUESTION # 117
Which of the following individuals is the first line of escalation for an unanswered query?

A. Medical Director
B. CDI Steering Committee
C. HIM/Coding Manager
D. CDI Manager

Answer: D

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 # 118
Which entity has the following regulation?
A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

A. Office of Inspector General
B. Office of the National Coordinator for Health Information Technology
C. Office for Civil Rights
D. Centers for Medicare & Medicaid Services

Answer: D

Explanation:
Explanation
The entity that has the following regulation is the Centers for Medicare & Medicaid Services (CMS), which is the federal agency that oversees the Medicare and Medicaid programs and sets the Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) for health care organizations that participate in these programs.
The regulation that requires a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, is part of the CoPs for Hospitals, which are located in 42 CFR §
482.24. This regulation was revised in 2007 to align with the Joint Commission's standard and to provide more flexibility and consistency for hospitals and practitioners. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
42 CFR § 482.243

NEW QUESTION # 119
Which of the following should be examined when developing documentation integrity projects?

A. Coding productivity statistics
B. Physician satisfaction surveys
C. Query rates from coding staff
D. CC and MCC capture rates

Answer: D

Explanation:
Explanation
The factor that should be examined when developing documentation integrity projects is CC and MCC capture rates. CC stands for complication or comorbidity, and MCC stands for major complication or comorbidity.
These are secondary diagnoses that affect the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality measures of the hospital. CC and MCC capture rates measure how well the clinical documentation reflects the presence and impact of these conditions on the patient's care. Examining CC and MCC capture rates can help to identify documentation improvement opportunities, goals, strategies, and outcomes4 References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 4:
https://my.ahima.org/store/product?id=67077

NEW QUESTION # 120
......

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