Valid CDIP Exam Dumps are Your best Choice to Pass

1. The key component of the auditing and monitoring process to ensure provider query response is to

2. 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?

3. Which of the following sources provide external benchmarks to examine the effectiveness of a facility's clinical documentation program?

4. Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner's role within the organization?

5. When writing a compliant query, best practice is to

6. Which of the following individuals is the first line of escalation for an unanswered query?

7. 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?

8. Yes/No queries may be used

9. 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?

10. 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?

11. The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program. The plan is to use case mix index (CMI) as a metric of CDI performance.

How will this metric be measured?

A. Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI

B. Over time with a focus on particular documentation improvement areas in addition to the overall CMI

C. Month-to-month and focus on patient volumes to determine the raise the overall CMI

D. Month-to-month to show CMI variability as a barometer of a specific month

12. Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

13. Whether or not queries should be kept as a permanent part of the medical record is decided by

14. The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

15. A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side.

The default code is

16. 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?

17. A resident returns to the long-term care facility following hospital care for pneumonia. The physician's orders and progress note state "Continue IV antibiotics for pneumonia - 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia".

Is it appropriate to code the pneumonia in this scenario?

18. Creating policies and procedures for the query process will help eliminate

19. Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?

20. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia.

What is best practice for fixing this mistake according to AHIMA?

21. A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate time frame.

What should the CDIP do next?

22. Combination codes are used to classify two diagnoses, a diagnosis with a manifestation, or a diagnosis

23. Which of the following is an example of a hospital-acquired condition when not present on admission?

A. Iatrogenic pneumothorax with lung biopsy

B. Iatrogenic pneumothorax with venous catheterization

C. Pressure ulcer stage II

D. Pressure ulcer stage III

24. A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0°. On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to

25. A clinical documentation integrity (CDI) program that is compliant with regulations from the facility's payors results in

26. 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

27. Which member of the clinical documentation integrity (CDI) team can help provide peer-to-peer level of education on the importance of accurate documentation and query responses?

28. The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to

29. Review the following query to determine if it is compliant:

Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?

Dehydration

Hyponatremia

Hypernatremia

Chronic kidney disease (indicate stage)

Other (please specify)

30. A query should include

31. Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?

32. 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?

33. A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs: BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia. Aspiration precautions and IV Clindamycin ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.

34. Educating physicians on severity of illness and risk of mortality is best accomplished by utilizing

35. 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?

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

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

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

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

36. A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition.

Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?

37. A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient's diagnosis.

Which response provides the highest level of specificity?

38. Which of the following is a clinical documentation integrity (CDI) financial impact measure?

39. 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?

40. An increase in claim denials has prompted a clinical documentation integrity (CDI) manager to engage the CDI physician advisor/champion in an effort to avoid future denials.

How does this strategy impact the goal?

A. The CDI manager will exclusively provide education.

B. Physicians will learn documentation integrity practices from peers.

C. Physicians can manage the documentation integrity process.

D. Clinicians will not require documentation integrity education.