CDIP Dumps By Pros - 1st Attempt Guaranteed Success [Q27-Q48]

NEW QUESTION 27
The correct coding for heart failure with preserved ejection fraction is

150.32 Chronic diastolic (congestive) heart failure

I50.20 Unspecified systolic (congestive) heart failure

I50.9 Heart failure, unspecified

I50.30 Unspecified diastolic (congestive) heart failure

NEW QUESTION 28
An organization dealing with staffing shortages has adopted a policy requiring clinical documentation integrity practitioner (CDIP) to stop reviewing any record after a major complication or co-morbidity is found. What is the unintended consequence of this?

Increase in case mix index

Reduced risk of clinical denials

Increased number of records reviewed by each CDIP

Decrease in severity of illness and risk of mortality

NEW QUESTION 29
A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is

Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient’s severity of illness can be captured with the most accurate coding assignment.

Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.

Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other.

Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.

NEW QUESTION 30
Which of the following is an example of a hospital-acquired condition when not present on admission?

Iatrogenic pneumothorax with lung biopsy

Iatrogenic pneumothorax with venous catheterization

Pressure ulcer stage II

Pressure ulcer stage III

NEW QUESTION 31
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?

Percent of insurance billings denied due to lack of record documentation

Number of coder queries regarding inconsistent physician record documentation

Results of a survey of physicians that asks about documentation practices

Incidence of redundancies in physician notes in a sample of hospital admissions

Explanation
According to the AHIMA CDIP Exam Preparation Guide, a documentation integrity project is a systematic process of identifying, analyzing, and improving the quality and accuracy of clinical documentation in the health record1. A documentation integrity project may have various purposes, such as enhancing patient safety, improving coding and reimbursement, or complying with regulatory standards1. One of the common issues that may affect the quality and accuracy of clinical documentation is the indiscriminate use of electronic copy and paste of patient information in records by physicians2. Copy and paste is a function that allows physicians to duplicate existing text in the record and paste it in a new destination, which may save time and effort, but also may introduce errors, inconsistencies, or redundancies in the documentation2. Therefore, to quantify the extent of the problem of copy and paste, the data that should be used is the incidence of redundancies in physician notes in a sample of hospital admissions. Redundancies are repeated or unnecessary information that may clutter the record and impair its readability and reliability3. By measuring the frequency and types of redundancies in physician notes, the hospital can assess the impact of copy and paste on the documentation quality and identify areas for improvement. The other options are not correct because they do not directly measure the problem of copy and paste. The percent of insurance billings denied due to lack of record documentation may reflect other issues besides copy and paste, such as incomplete or inaccurate documentation, coding errors, or payer policies4. The number of coder queries regarding inconsistent physician record documentation may indicate the presence of copy and paste, but it may also depend on other factors such as coder knowledge, query guidelines, or query response rate. The results of a survey of physicians that asks about documentation practices may provide some insight into the perceptions and attitudes of physicians regarding copy and paste, but it may not reflect the actual extent or impact of the problem on the documentation quality.
CDIP Exam Preparation Guide – AHIMA
Auditing Copy and Paste – AHIMA
Copy/Paste: Prevalence, Problems, and Best Practices – AHIMA
Documentation Denials: How to Avoid Them – AAPC
[Q&A: Querying for clinical validation | ACDIS]

NEW QUESTION 32
When a change in departmental workflow is necessary, the first step is to

define the gaps and solutions

set realistic timelines

re-engineer the process

assess the current workflow

NEW QUESTION 33
Proposed changes to the inpatient prospective payment system (IPPS) take effect on

October 1

January 1

July 1

April 1

NEW QUESTION 34
Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?

Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)

Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)

Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), Office of Inspector General (OIG)

Center for Improvement in Healthcare (CIHQ), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)

NEW QUESTION 35
The provider was queried because the patient met clinical criteria for acute hypoxic respiratory failure. The response to the query was different than what was expected by the clinical documentation integrity practitioner (CDIP). What should the CDIP do?

Record the query response as disagreed

Have a different CDIP query the provider

Revise the query and send it back to the provider

Implement the department’s escalation process

Explanation
If the provider’s response to the query is different than what was expected by the CDIP, the CDIP should implement the department’s escalation process to ensure the validity and accuracy of the documentation and the coded data. The escalation process is a standardized procedure that involves a manager, committee, or other supervisory position to review and assess the query and the response, and to determine the appropriate next steps. The escalation process may include contacting the provider for clarification, education, or feedback; consulting with a physician advisor/champion or a coding auditor; or reporting the issue to a higher authority or regulatory body. The escalation process should be documented and communicated clearly and respectfully to all parties involved.
A: Record the query response as disagreed. This is not a sufficient action to take if the provider’s response to the query is different than what was expected by the CDIP. Recording the query response as disagreed may indicate a lack of agreement or consensus between the CDIP and the provider, but it does not address the underlying issue of documentation validity or accuracy. It may also create a negative impression or relationship between the CDIP and the provider.
B: Have a different CDI query the provider. This is not an appropriate action to take if the provider’s response to the query is different than what was expected by the CDIP. Having a different CDI query the provider may create confusion, inconsistency, or redundancy in the query process. It may also undermine the credibility or authority of the original CDI who queried the provider.
C: Revise the query and send it back to the provider. This is not a recommended action to take if the provider’s response to the query is different than what was expected by the CDIP. Revising the query and sending it back to the provider may imply that the CDI is dissatisfied or disagreeing with the provider’s response, which may be perceived as disrespectful or confrontational. It may also suggest that the CDI is trying to influence or coerce the provider to change their response, which may compromise the integrity and compliance of the query process.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Guidelines for Achieving a Compliant Query Practice-2022 Update | ACDIS Guidelines for Achieving a Compliant Query Practice (2019 Update) – AHIMA The Provider Query Toolkit: A Guide to Compliant Practices

NEW QUESTION 36
Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?

No query is needed because the patient was dehydrated

Query the physician to see if acute renal failure is clinically supported

Query the physician to see if acute renal failure with tubular necrosis is supported

Code acute renal failure since symptoms are there and documented

NEW QUESTION 37
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?

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

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

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

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

Explanation
APR-DRGs are a patient classification system that assigns each inpatient stay to one of more than 300 base APR-DRGs, and then further stratifies each base APR-DRG into four levels of severity of illness (SOI) and risk of mortality (ROM), based on the number, nature, and interaction of complications and comorbidities (CCs) and major CCs (MCCs). SOI reflects the extent of physiologic decompensation or organ system loss of function, while ROM reflects the likelihood of dying. Both SOI and ROM are used to adjust payment rates, quality indicators, and performance measures for hospitals and other healthcare providers.
The CDI manager can gain more information about the potential opportunities for improvement by auditing focused APR-DRGs that have a high impact on SOI/ROM levels, such as those that have a large variation in relative weights across the four severity levels, or those that have a high frequency or volume of cases. The audit can help identify the documentation gaps, inconsistencies, or inaccuracies that may affect the assignment of SOI/ROM levels, such as missing, vague, or conflicting diagnoses, procedures, or clinical indicators. The audit can also help evaluate the CDI team’s performance in terms of query rate, response rate, agreement rate, and accuracy rate. Based on the audit findings, the CDI manager can develop an education plan for both the CDI team and the physicians to address the specific documentation improvement areas and provide feedback and guidance on best practices.
A: Audit cases for missed diagnosis by the CDI practitioner to target in the education plan. This is not the best way to gain more information about the situation, because it may not capture all the factors that affect SOI/ROM levels, such as procedures, clinical indicators, or interactions among diagnoses. It may also focus only on the CDI practitioner’s performance, without considering the physician’s role in documentation quality and completeness.
B: Audit focused cases by physicians that have a higher SOI/ROM for education plan. This is not a valid way to gain more information about the situation, because it may not identify the documentation improvement opportunities for cases that have a lower SOI/ROM than expected, based on their clinical complexity and acuity. It may also create a perception of bias or favoritism among physicians, if only some are selected for audit and education.
C: Audit cases that have high SOI/ROM assigned by coders for education and follow-up. This is not a reliable way to gain more information about the situation, because it may not reflect the true SOI/ROM levels of the cases, if there are errors or discrepancies in coding or grouping. It may also overlook the documentation improvement opportunities for cases that have low SOI/ROM assigned by coders, despite having high clinical complexity and acuity.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
3M™ All Patient Refined Diagnosis Related Groups (APR DRGs) | 3M United States Q&A: Understanding SOI and ROM in the APR-DRG system | ACDIS Use SOI/ROM scores to enhance CDI program effectiveness | ACDIS

NEW QUESTION 38
A patient’s progress note states “The patient has chronic systolic heart failure”. After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?

The patient has chronic systolic heart failure.

The patient has acute on chronic systolic heart failure.

The patient did have an exacerbation of heart failure.

The patient has decompensated systolic heart failure.

NEW QUESTION 39
When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to

code the first condition listed

query for clarification

not code either diagnosis

code both diagnoses

NEW QUESTION 40
What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

Multiple-choice

Open-ended

Verbal

Yes/No

NEW QUESTION 41
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?

Update medical records with unsigned physician responses

Allow physician responses via e-mail

Provide education to physicians on query process

Require the CDIP to call physicians to follow up

NEW QUESTION 42
The facility has received a clinical validation denial for sepsis. The denial states sepsis is not a clinically valid diagnosis because it does not meet Sepsis-3 criteria. The facility has a policy stating it uses Sepsis-2 criteria.
What is the BEST next step?

Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.

Appeal the denial because all payors must use the hospital’s sepsis criteria when reviewing their claims.

Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.

Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.

NEW QUESTION 43
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?

Complete the documentation immediately after the provider’s response

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

Complete the documentation when there is a provider agreement

Complete the documentation at the time of discussion or immediately following

NEW QUESTION 44
A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician’s documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit. Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD.
Discharge diagnoses:
1. Pneumonia
2. COPD
3. Current smoker
What is the correct diagnostic related group assignment?

DRG 190 Chronic Obstructive Pulmonary Disease with MCC

DRG 202 Bronchitis and Asthma with CC/MCC

DRG 204 Respiratory Signs and Symptoms

DRG 194 Simple Pneumonia and Pleurisy without CC/MCC

NEW QUESTION 45
After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?

Expand the CDI program to larger areas in outpatient clinics

Prioritize to focus on efforts with the largest return on investment

Identify key metrics to develop program measures for coders

Establish a CDI steering committee to build a strong foundation

NEW QUESTION 46
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?

Look for wound care documentation

Read the nursing admission notes

Query the attending provider

Review the history and physical

NEW QUESTION 47
The third quarter target concurrent physician query response rate for each physician in a hospital gastroenterology department was 80%. Nine physicians met or exceeded this metric; however, two physicians had third quarter concurrent physician query response rates of 19% and 64%. What is the best course of action for the clinical documentation integrity (CDI) physician advisor/champion?

Schedule a group meeting with all physicians

Schedule individual meetings with each physician

Schedule individual meetings with each low-performing physician

Schedule a meeting with the chair of the gastroenterology department

NEW QUESTION 48
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?

61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural

61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma

61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion

61105 Twist drill hole subdural/ventricular puncture