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AHIMA CDIP - Certified Documentation Integrity Practitioner

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Total 140 questions

Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?

A.

Inconsistent clinically relevant queries

B.

CDI practitioners sending multiple queries to hospitalist physicians

C.

The physician advisor/champion's interventions with noncompliant physicians

D.

Providing many lectures, newsletters, tip sheets, and pocket cards for physician education

When a change in departmental workflow is necessary, the first step is to

A.

define the gaps and solutions

B.

set realistic timelines

C.

re-engineer the process

D.

assess the current workflow

Which of the following is an appropriate first step to address physicians with low query response rates?

A.

An educational session between the clinical documentation integrity practitioner (CDIP) and physician

B.

The medical staff review the physician's noncompliance to consider sanctions

C.

The physician receives a suspension until query responses are improved

D.

A meeting between the physician advisor/champion and the noncompliant physician

The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a

compliance risk for this follow up failure according to AHIMA's Guidelines for Achieving a Compliant Query Practice?

A.

Complete the documentation immediately after the provider's response

B.

Complete the documentation at the end of the day when entering cases reviewed

C.

Complete the documentation when there is a provider agreement

D.

Complete the documentation at the time of discussion or immediately following

When are concurrent queries initiated?

A.

After the health record has been coded

B.

After discharge of the patient

C.

While the patient is hospitalized

D.

Before patient is admitted

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

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

The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.

What should the CDI manager keep in mind when discussing this observation with physicians?

A.

The indicator is a key factor of measurement for quality reports.

B.

The query rate is too high while the agreement rate is low.

C.

The query response rate directly correlates to quality reports.

D.

The diagnosis with a higher degree of specificity has a lower severity of illness.

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?

A.

Update medical records with unsigned physician responses

B.

Allow physician responses via e-mail

C.

Provide education to physicians on query process

D.

Require the CDIP to call physicians to follow up

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 rebilling is permissible when queries are answered after the initial bill.

B.

A post-bill query rarely occurs as a result of an audit or other internal monitor.

C.

A second bill should not be submitted when the first bill was incomplete.

D.

A post bill query is not appropriate when an error is found after an audit.