[Jun-2024] CDIP Pre-Exam Practice Tests | Exam Questions and Answers for AHIMA CDI Study Guide
Certified Documentation Integrity Practitioner Certification Sample Questions
NEW QUESTION # 59
What type of laboratory test is a creatinine test?
- A. Serology
- B. Chemistry
- C. Microbiology
- D. Hematology
Answer: B
NEW QUESTION # 60
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?
- A. Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus
- B. Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus
- C. Right lower quadrant abdominal pain, fever, vomiting, leukocytosis
- D. Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis
Answer: B
Explanation:
Explanation
The proper sequencing of the principal and secondary diagnoses in this case is as follows:
Principal diagnosis: Acute appendicitis. This is the condition, after study, that occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. The patient was admitted for laparoscopic surgery, which is a definitive treatment for acute appendicitis. The physician documented "possible acute appendicitis or probable Meckel diverticulitis" as the cause of the right lower quadrant abdominal pain. According to the AHA's Coding Clinic, Fourth Quarter 2016, pp.
147-148, when a physician documents two diagnoses connected by "or", coders should query the physician for clarification if possible. However, if a query is not possible or not answered, coders should assign codes for both conditions, unless one of them has been ruled out or confirmed by further testing or treatment. In this case, there is no indication that either acute appendicitis or Meckel diverticulitis has been ruled out or confirmed by further testing or treatment. Therefore, both conditions should be coded and reported. However, only one of them can be the principal diagnosis. Since acute appendicitis is more commonly associated with laparoscopic surgery than Meckel diverticulitis, and since it has a higher relative weight than Meckel diverticulitis under the MS-DRG system, it is reasonable to select acute appendicitis as the principal diagnosis 23.
Secondary diagnosis: Right lower quadrant abdominal pain. This is a sign or symptom that is associated with the principal diagnosis and requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. The patient presented with right lower quadrant abdominal pain as a manifestation of acute appendicitis or Meckel diverticulitis. The pain required clinical evaluation by abdominal ultrasound and therapeutic treatment by laparoscopic surgery. Therefore, it should be coded and reported as a secondary diagnosis 4.
Secondary diagnosis: Type I diabetes mellitus. This is a chronic condition that affects the patient's care in terms of requiring diagnostic or therapeutic services or affecting patient outcomes or resource utilization. The patient has a history of type I diabetes mellitus and received an injection of neutral protamine Hagedorn insulin to normalize the blood sugar level prior to surgery. Therefore, it should be coded and reported as a secondary diagnosis 4.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section II.A 3: AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Fourth Quarter 2016 4: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section III.C : AHIMA CDIP Exam Prep, Fourth Edition https://my.ahima.org/store/product?id=67077
NEW QUESTION # 61
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 type of COPD such as severe asthma.
- C. Query the physician to clarify for clinical significance of the CXR results.
- D. Query the physician to clarify if CXR result means patient has pneumonia.
Answer: D
NEW QUESTION # 62
The correct coding for heart failure with preserved ejection fraction is
- A. 150.32 Chronic diastolic (congestive) heart failure
- B. I50.20 Unspecified systolic (congestive) heart failure
- C. I50.30 Unspecified diastolic (congestive) heart failure
- D. I50.9 Heart failure, unspecified
Answer: C
Explanation:
Explanation
According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023, heart failure with preserved ejection fraction (HFpEF) is also known as diastolic heart failure or heart failure with normal ejection fraction1. The code category for diastolic heart failure is I50.3-, which includes unspecified diastolic (congestive) heart failure (I50.30), acute diastolic (congestive) heart failure (I50.31), chronic diastolic (congestive) heart failure (I50.32), and acute on chronic diastolic (congestive) heart failure (I50.33)1. If the documentation does not specify the acuity of the diastolic heart failure, the default code is I50.301. Therefore, the correct coding for heart failure with preserved ejection fraction is I50.30.
References:
ICD-10-CM Official Guidelines for Coding and Reporting FY 20231
NEW QUESTION # 63
The best approach in resolving unanswered queries is to
- A. notify the physician advisor/champion that the physician has not responded to the query
- B. notify the coding team of the physician's unanswered query
- C. review the facility's query policies and procedures
- D. contact the physician repeatedly until he/she responds to the query
Answer: C
Explanation:
Explanation
facilities must develop an escalation policy for unanswered queries and address any medical staff concerns regarding queries1. If a query does not receive an appropriate professional response, the case should be referred for further review in accordance with the facility's written escalation policy2. 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 level1. The policies should reflect a method of response that can realistically occur for the organization1. Therefore, reviewing the facility's query policies and procedures is the best approach to ensure compliance and consistency in handling unanswered queries.
The other options are not advisable because they either involve skipping the escalation policy, notifying the physician advisor/champion without proper review or feedback, contacting the physician repeatedly without respecting their time or availability, or notifying the coding team without resolving the query issue.
NEW QUESTION # 64
A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?
- A. The associated diagnosis directly on the query form
- B. That the blood loss was not clinically significant
- C. A cause-and-effect relationship between anemia and the underlying cause
- D. The associated diagnosis and the clinical rationale in the progress notes
Answer: D
Explanation:
Explanation
The physician needs to document the associated diagnosis and the clinical rationale in the progress notes for the CDIP to record the query as answered and agreed because this is the best way to ensure that the health record reflects the patient's condition and treatment accurately and completely. The associated diagnosis is the condition that caused or contributed to the blood loss and the need for transfusion, such as acute blood loss anemia, hemorrhage, or trauma. The clinical rationale is the explanation of how the diagnosis is supported by the clinical indicators, such as laboratory values, vital signs, symptoms, or procedures. Documenting the associated diagnosis and the clinical rationale in the progress notes also helps to avoid any confusion or inconsistency with other parts of the health record, such as the discharge summary or the coding. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Guidelines for Achieving a Compliant Query Practice (2019 Update)3
NEW QUESTION # 65
Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?
- A. Precise
- B. Reliable
- C. Legible
- D. Complete
Answer: B
Explanation:
Explanation
According to AHIMA, clinical documentation is at the core of every patient encounter and it must be meaningful to accurately reflect the patient's disease burden and scope of services provided. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible1. Reliability is one of the criteria for clinical documentation that means the content of the record is trustworthy, safe, and yielding the same result when repeated1. Reliability ensures that the documentation is consistent with the clinical evidence and reasoning, and that it can be verified by other sources or methods. Reliability also implies that the documentation is free from errors, omissions, contradictions, or ambiguities that could compromise its validity or usefulness1.
References:
Clinical Documentation Integrity Education & Training | AHIMA1
NEW QUESTION # 66
Which of the following clinical documentation integrity (CDI) dashboard metrics is frequently used to help evaluate the credibility of CDI practitioner queries and the success of the CDI program?
- A. Provider agreement rate
- B. Provider response rate
- C. CDI agreement rate
- D. CDI query rate
Answer: A
Explanation:
Explanation
The provider agreement rate is the percentage of queries that result in a change in the documentation or coding that is consistent with the query. It is a measure of the accuracy and appropriateness of the queries, as well as the provider's acceptance of the CDI program's recommendations. A high provider agreement rate indicates that the CDI practitioners are asking relevant and compliant queries that improve the quality and specificity of the documentation. The other options are not directly related to the credibility of the queries or the success of the CDI program. The CDI agreement rate is the percentage of queries that agree with the coder's final DRG assignment. The CDI query rate is the percentage of records that generate a query from the CDI practitioner.
The provider response rate is the percentage of queries that receive a response from the provider.
NEW QUESTION # 67
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. Read the nursing admission notes
- B. Review the history and physical
- C. Query the attending provider
- D. Look for wound care documentation
Answer: B
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 # 68
Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?
- A. Value and mission statements
- B. Reporting and the use of technology
- C. Diagnostic related groups and revenue cycle
- 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 # 69
When writing a compliant query, best practice is to
- A. include all relevant clinical indicators
- B. use a yes/no query format for specificity of a diagnosis
- C. direct the physician to a specific diagnosis
- D. use the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present
Answer: A
Explanation:
Explanation
One of the best practices for writing a compliant query is to include all relevant clinical indicators from the health record that support the need for clarification and the query options. Clinical indicators are objective and measurable signs, symptoms, laboratory results, diagnostic test results, medications, treatments, and other documented findings that are related to a specific diagnosis or condition. Including clinical indicators helps to provide the rationale for the query, avoid leading or suggesting a desired response, and ensure that the query is based on evidence and not assumptions. The other options are not best practices for writing a compliant query.
Directing the physician to a specific diagnosis is leading and noncompliant. Using the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present is vague and imprecise. Using a yes/no query format for specificity of a diagnosis is discouraged, as it limits the provider's choices and may not capture the true clinical picture.
NEW QUESTION # 70
Which of the following is an example of a hospital-acquired condition when not present on admission?
- A. Iatrogenic pneumothorax with venous catheterization
- B. Iatrogenic pneumothorax with lung biopsy
- C. Pressure ulcer stage II
- D. Pressure ulcer stage III
Answer: D
Explanation:
Explanation
A hospital-acquired condition (HAC) is an undesirable situation or condition that affects a patient and that arose during a stay in a hospital or medical facility. CMS has identified 14 categories of HACs for which it will not pay the higher DRG rate if the condition was not present on admission (POA). One of these categories is stage III and IV pressure ulcers. A pressure ulcer is damage to the skin and underlying tissue caused by prolonged pressure on the skin. Stage III pressure ulcers involve full-thickness skin loss with damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents as a deep crater with or without undermining of adjacent tissue.
A: Iatrogenic pneumothorax with lung biopsy is not a HAC, because it is not included in the CMS HAC list.
Iatrogenic pneumothorax is a HAC only when it occurs with venous catheterization.
B: Iatrogenic pneumothorax with venous catheterization is a HAC, but it may be present on admission if the venous catheterization was performed before the admission to the hospital.
C: Pressure ulcer stage II is not a HAC, because only stage III and IV pressure ulcers are included in the CMS HAC list. Stage II pressure ulcers involve partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Hospital Acquired Conditions | CMS ICD-10 HAC List | CMS Bedsores (pressure ulcers) - Symptoms and causes - Mayo Clinic
NEW QUESTION # 71
When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to
- A. code the first condition listed
- B. not code either diagnosis
- C. code both diagnoses
- D. query for clarification
Answer: C
Explanation:
Explanation
When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to code both diagnoses, as long as they are not mutually exclusive. Comparative contrasting diagnoses are those that are considered as possible alternatives or differentials for the patient's condition, such as pneumonia versus bronchitis, or appendicitis versus diverticulitis. Coding both diagnoses will capture the clinical uncertainty and complexity of the case, and will allow for accurate reporting and reimbursement. References: :
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf :
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 72
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. AHA Coding Clinic for ICD-10-CM
- B. AMA CPT Assistant
- C. Faye Brown's Coding Handbook
- D. ICD-10-CM Official Guidelines for Coding and Reporting
Answer: D
Explanation:
Explanation
The coding reference that should be used to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes 1 and 2 is the ICD-10-CM Official Guidelines for Coding and Reporting. This document provides the conventions and instructions for the proper use of the ICD-10-CM classification system, including the definitions and examples of the Includes Notes and Excludes Notes 1 and 2. The document is updated annually by the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), and is available online at 2. The other coding references listed are not specific to ICD-10-CM or do not contain the general rules for the Includes Notes and Excludes Notes 1 and 2.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 4
NEW QUESTION # 73
Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?
- A. The physician advisor/champion's interventions with noncompliant physicians
- B. CDI practitioners sending multiple queries to hospitalist physicians
- C. Inconsistent clinically relevant queries
- D. Providing many lectures, newsletters, tip sheets, and pocket cards for physician education
Answer: C
Explanation:
Explanation
Inconsistent clinically relevant queries may make physicians lose respect for CDI efforts and disengage because they may perceive them as irrelevant, redundant, or contradictory. Clinically relevant queries are those that affect the quality of care, patient safety, severity of illness, risk of mortality, or reimbursement.
Inconsistent queries may result from lack of standardization, conflicting guidelines, poor communication, or lack of clinical validation. To avoid inconsistency, CDI practitioners should follow best practices such as using evidence-based criteria, adhering to query policies and procedures, collaborating with coding and quality staff, and seeking feedback from physicians and physician advisors 2.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 136 3 2: Proactive CDI: Tackling the Problem of Physician Engagement 4
NEW QUESTION # 74
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?
- A. Productivity standards
- B. Mission
- C. Review schedule
- D. Milestones
Answer: B
Explanation:
Explanation
Sharing the mission of the CDI program should be done to ensure a clear sense of what CDI is and the CDI practitioner's role within the organization. The mission statement defines the purpose, goals, and values of the CDI program, and how it aligns with the organization's vision and strategy. The mission statement also communicates the benefits and expectations of the CDI program to various stakeholders, such as providers, executives, coders, quality staff, and patients. The mission statement can help establish the credibility, professionalism, and identity of the CDI practitioners, and guide their daily activities and decisions 2.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: Mission CDI: Guiding goals, values, and principles 1
NEW QUESTION # 75
The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to
- A. determine if only the treatment is documented and there is no diagnosis documented
- B. identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
- C. look for documented conditions that have well supported accompanying clinical criteria
- D. watch for reportable conditions or conditions that are unambiguous or otherwise complete
Answer: A
NEW QUESTION # 76
The key component of the auditing and monitoring process to ensure provider query response is to
- A. audit individual providers to indicate improvement in health record documentation
- B. review queries retrospectively to ensure that they are completed according to documented Policies and procedures
- C. make sure that the language in the query is not leading or otherwise inappropriate
- D. have a process in place for ongoing education and training of the staff involved in conducting provider queries
Answer: B
NEW QUESTION # 77
In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?
- A. Emphasize the Medicare requirements for documentation
- B. Explanations on how severity of illness and risk of mortality impact reimbursement
- C. Examples from the hospital's actual cases
- D. The latest Medicare Provider and Analysis Review data
Answer: C
Explanation:
Explanation
In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, examples from the hospital's actual cases are the most effective for physicians in a hospital. Examples from the hospital's actual cases can show how specific documentation elements, such as diagnoses, procedures, complications, comorbidities, and present on admission indicators, can affect the severity of illness and risk of mortality scores of the patients, as well as the hospital's performance and reputation. Examples from the hospital's actual cases can also provide feedback and education to the physicians on how to improve their documentation practices and standards. References: :
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf :
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 78
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