{"id":2398,"date":"2026-04-07T09:41:01","date_gmt":"2026-04-07T09:41:01","guid":{"rendered":"https:\/\/blog.topexamcollection.com\/?p=2398"},"modified":"2026-04-07T09:41:01","modified_gmt":"2026-04-07T09:41:01","slug":"cdip-dumps-by-pros-1st-attempt-guaranteed-success-q27-q48","status":"publish","type":"post","link":"https:\/\/blog.topexamcollection.com\/de\/2026\/04\/cdip-dumps-by-pros-1st-attempt-guaranteed-success-q27-q48\/","title":{"rendered":"CDIP Dumps By Pros &#8211; 1st Attempt Guaranteed Success [Q27-Q48]"},"content":{"rendered":"\n\n<div class=\"kk-star-ratings kksr-auto kksr-align-left kksr-valign-top\"\n    data-payload='{&quot;align&quot;:&quot;left&quot;,&quot;id&quot;:&quot;2398&quot;,&quot;slug&quot;:&quot;default&quot;,&quot;valign&quot;:&quot;top&quot;,&quot;ignore&quot;:&quot;&quot;,&quot;reference&quot;:&quot;auto&quot;,&quot;class&quot;:&quot;&quot;,&quot;count&quot;:&quot;1&quot;,&quot;legendonly&quot;:&quot;&quot;,&quot;readonly&quot;:&quot;&quot;,&quot;score&quot;:&quot;4&quot;,&quot;starsonly&quot;:&quot;&quot;,&quot;best&quot;:&quot;5&quot;,&quot;gap&quot;:&quot;5&quot;,&quot;greet&quot;:&quot;Rate this post&quot;,&quot;legend&quot;:&quot;4\\\/5 - (1 vote)&quot;,&quot;size&quot;:&quot;24&quot;,&quot;title&quot;:&quot;CDIP Dumps By Pros - 1st Attempt Guaranteed Success [Q27-Q48]&quot;,&quot;width&quot;:&quot;113.5&quot;,&quot;_legend&quot;:&quot;{score}\\\/{best} - ({count} {votes})&quot;,&quot;font_factor&quot;:&quot;1.25&quot;}'>\n            \n<div class=\"kksr-stars\">\n    \n<div class=\"kksr-stars-inactive\">\n            <div class=\"kksr-star\" data-star=\"1\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n            <div class=\"kksr-star\" data-star=\"2\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n            <div class=\"kksr-star\" data-star=\"3\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n            <div class=\"kksr-star\" data-star=\"4\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n            <div class=\"kksr-star\" data-star=\"5\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n    <\/div>\n    \n<div class=\"kksr-stars-active\" style=\"width: 113.5px;\">\n            <div class=\"kksr-star\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n            <div class=\"kksr-star\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n            <div class=\"kksr-star\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n            <div class=\"kksr-star\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n            <div class=\"kksr-star\" style=\"padding-right: 5px\">\n            \n\n<div class=\"kksr-icon\" style=\"width: 24px; height: 24px;\"><\/div>\n        <\/div>\n    <\/div>\n<\/div>\n                \n\n<div class=\"kksr-legend\" style=\"font-size: 19.2px;\">\n            4\/5 - (1 vote)    <\/div>\n    <\/div>\n<p><span style=\"color: red;font-size: 18px\"><strong>CDIP Dumps By Pros &#8211; 1st Attempt Guaranteed Success<\/strong><\/span><\/p>\n<p><span style=\"color: red\"><strong>100% Guarantee Download CDIP Exam Dumps PDF Q&amp;A<\/strong><\/span><\/p>\n<div id=\"watu_quiz\" class=\"quiz-area single-page-quiz\">\n<form action=\"\" method=\"post\" class=\"quiz-form \" id=\"quiz-983\" >\n<div class='watu-question' id='question-1'><div class='question-content'><p><strong>NEW QUESTION 27<\/strong><br \/>The correct coding for heart failure with preserved ejection fraction is<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19381' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75065' \/><div class='watu-question-choice'><input type='radio' name='answer-19381[]' id='answer-id-75065' class='answer answer-1 js-answer-label answerof-19381' value='75065' \/>&nbsp;<label for='answer-id-75065' id='answer-label-75065' class='js-answer-label answer label-1'><span class='answer'>150.32 Chronic diastolic (congestive) heart failure<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75066' \/><div class='watu-question-choice'><input type='radio' name='answer-19381[]' id='answer-id-75066' class='answer answer-1 js-answer-label answerof-19381' value='75066' \/>&nbsp;<label for='answer-id-75066' id='answer-label-75066' class='js-answer-label answer label-1'><span class='answer'>I50.20 Unspecified systolic (congestive) heart failure<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75067' \/><div class='watu-question-choice'><input type='radio' name='answer-19381[]' id='answer-id-75067' class='answer answer-1 js-answer-label answerof-19381' value='75067' \/>&nbsp;<label for='answer-id-75067' id='answer-label-75067' class='js-answer-label answer label-1'><span class='answer'>I50.9 Heart failure, unspecified<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75068' \/><div class='watu-question-choice'><input type='radio' name='answer-19381[]' id='answer-id-75068' class='answer answer-1 php-answer-label answerof-19381' value='75068' \/>&nbsp;<label for='answer-id-75068' id='answer-label-75068' class='php-answer-label answer label-1'><span class='answer'>I50.30 Unspecified diastolic (congestive) heart failure<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>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.<br\/>References:<br\/>ICD-10-CM Official Guidelines for Coding and Reporting FY 20231<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(1,this)' id='btn-1' value='See Answer'  \/><input type='hidden' id='questionType1' value='radio' class=''><\/div><div class='watu-question' id='question-2'><div class='question-content'><p><strong>NEW QUESTION 28<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19382' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75069' \/><div class='watu-question-choice'><input type='radio' name='answer-19382[]' id='answer-id-75069' class='answer answer-2 js-answer-label answerof-19382' value='75069' \/>&nbsp;<label for='answer-id-75069' id='answer-label-75069' class='js-answer-label answer label-2'><span class='answer'>Increase in case mix index<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75070' \/><div class='watu-question-choice'><input type='radio' name='answer-19382[]' id='answer-id-75070' class='answer answer-2 js-answer-label answerof-19382' value='75070' \/>&nbsp;<label for='answer-id-75070' id='answer-label-75070' class='js-answer-label answer label-2'><span class='answer'>Reduced risk of clinical denials<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75071' \/><div class='watu-question-choice'><input type='radio' name='answer-19382[]' id='answer-id-75071' class='answer answer-2 js-answer-label answerof-19382' value='75071' \/>&nbsp;<label for='answer-id-75071' id='answer-label-75071' class='js-answer-label answer label-2'><span class='answer'>Increased number of records reviewed by each CDIP<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75072' \/><div class='watu-question-choice'><input type='radio' name='answer-19382[]' id='answer-id-75072' class='answer answer-2 php-answer-label answerof-19382' value='75072' \/>&nbsp;<label for='answer-id-75072' id='answer-label-75072' class='php-answer-label answer label-2'><span class='answer'>Decrease in severity of illness and risk of mortality<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>Severity of illness (SOI) and risk of mortality (ROM) are two metrics that measure the complexity and acuity of a patient&#8217;s condition, 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 divided into four levels: minor, moderate, major, or extreme. These metrics are used to adjust payment rates, quality indicators, and performance measures for hospitals and other healthcare providers.<br\/>If a CDIP stops reviewing any record after a major CC is found, they may miss other CCs or MCCs that could affect the patient&#8217;s SOI and ROM levels. For example, a patient with pneumonia and sepsis would have a major CC (pneumonia) and an MCC (sepsis). If the CDIP stops reviewing the record after finding pneumonia, they would not capture sepsis, which would increase the patient&#8217;s SOI and ROM levels from major to extreme.<br\/>This would result in underreporting the patient&#8217;s true complexity and acuity, and potentially lead to lower reimbursement, lower quality scores, and higher denial risk.<br\/>Therefore, the unintended consequence of this policy is a decrease in SOI and ROM levels for patients who have more than one CC or MCC.<br\/>References:<br\/>CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Q&amp;A: Understanding SOI and ROM in the APR-DRG system<br\/>3M\u2122 All Patient Refined Diagnosis Related Groups (APR DRGs)<br\/>Severity of illness | definition of severity of illness by Medical dictionary Using Severity Adjustment Classification for Hospital Internal and External Comparisons<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(2,this)' id='btn-2' value='See Answer'  \/><input type='hidden' id='questionType2' value='radio' class=''><\/div><div class='watu-question' id='question-3'><div class='question-content'><p><strong>NEW QUESTION 29<\/strong><br \/>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<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19383' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75073' \/><div class='watu-question-choice'><input type='radio' name='answer-19383[]' id='answer-id-75073' class='answer answer-3 js-answer-label answerof-19383' value='75073' \/>&nbsp;<label for='answer-id-75073' id='answer-label-75073' class='js-answer-label answer label-3'><span class='answer'>Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.<br \/>Please order further tests so the patient&#8217;s severity of illness can be captured with the most accurate coding assignment.<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75074' \/><div class='watu-question-choice'><input type='radio' name='answer-19383[]' id='answer-id-75074' class='answer answer-3 js-answer-label answerof-19383' value='75074' \/>&nbsp;<label for='answer-id-75074' id='answer-label-75074' class='js-answer-label answer label-3'><span class='answer'>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.<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75075' \/><div class='watu-question-choice'><input type='radio' name='answer-19383[]' id='answer-id-75075' class='answer answer-3 php-answer-label answerof-19383' value='75075' \/>&nbsp;<label for='answer-id-75075' id='answer-label-75075' class='php-answer-label answer label-3'><span class='answer'>Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.<br \/>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.<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75076' \/><div class='watu-question-choice'><input type='radio' name='answer-19383[]' id='answer-id-75076' class='answer answer-3 js-answer-label answerof-19383' value='75076' \/>&nbsp;<label for='answer-id-75076' id='answer-label-75076' class='js-answer-label answer label-3'><span class='answer'>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.<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>According to the AHIMA\/ACDIS Query Practice Brief, a compliant query should provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement1. Option C meets these criteria, as it provides a list of possible diagnoses that are relevant to the patient&#8217;s condition and asks the provider to indicate which one they are treating. Option C also does not imply or suggest a preferred answer or outcome, and allows the provider to choose unable to determine or other if none of the listed options apply. Option A is not compliant, as it does not provide any answer options and implies that the provider should order more tests to capture a higher severity of illness. Option B is not compliant, as it provides only one answer option and suggests that the provider should document it based on the clinical indicators. Option D is not compliant, as it provides only one answer option and implies that the provider should document it based on the indications. References:<br\/>Guidelines for Achieving a Compliant Query Practice (2019 Update) &#8211; AHIMA<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(3,this)' id='btn-3' value='See Answer'  \/><input type='hidden' id='questionType3' value='radio' class=''><\/div><div class='watu-question' id='question-4'><div class='question-content'><p><strong>NEW QUESTION 30<\/strong><br \/>Which of the following is an example of a hospital-acquired condition when not present on admission?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19384' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75077' \/><div class='watu-question-choice'><input type='radio' name='answer-19384[]' id='answer-id-75077' class='answer answer-4 js-answer-label answerof-19384' value='75077' \/>&nbsp;<label for='answer-id-75077' id='answer-label-75077' class='js-answer-label answer label-4'><span class='answer'>Iatrogenic pneumothorax with lung biopsy<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75078' \/><div class='watu-question-choice'><input type='radio' name='answer-19384[]' id='answer-id-75078' class='answer answer-4 js-answer-label answerof-19384' value='75078' \/>&nbsp;<label for='answer-id-75078' id='answer-label-75078' class='js-answer-label answer label-4'><span class='answer'>Iatrogenic pneumothorax with venous catheterization<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75079' \/><div class='watu-question-choice'><input type='radio' name='answer-19384[]' id='answer-id-75079' class='answer answer-4 js-answer-label answerof-19384' value='75079' \/>&nbsp;<label for='answer-id-75079' id='answer-label-75079' class='js-answer-label answer label-4'><span class='answer'>Pressure ulcer stage II<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75080' \/><div class='watu-question-choice'><input type='radio' name='answer-19384[]' id='answer-id-75080' class='answer answer-4 php-answer-label answerof-19384' value='75080' \/>&nbsp;<label for='answer-id-75080' id='answer-label-75080' class='php-answer-label answer label-4'><span class='answer'>Pressure ulcer stage III<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>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.<br\/>A: Iatrogenic pneumothorax with lung biopsy is not a HAC, because it is not included in the CMS HAC list.<br\/>Iatrogenic pneumothorax is a HAC only when it occurs with venous catheterization.<br\/>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.<br\/>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.<br\/>References:<br\/>CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Hospital Acquired Conditions | CMS ICD-10 HAC List | CMS Bedsores (pressure ulcers) &#8211; Symptoms and causes &#8211; Mayo Clinic<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(4,this)' id='btn-4' value='See Answer'  \/><input type='hidden' id='questionType4' value='radio' class=''><\/div><div class='watu-question' id='question-5'><div class='question-content'><p><strong>NEW QUESTION 31<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19385' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75081' \/><div class='watu-question-choice'><input type='radio' name='answer-19385[]' id='answer-id-75081' class='answer answer-5 js-answer-label answerof-19385' value='75081' \/>&nbsp;<label for='answer-id-75081' id='answer-label-75081' class='js-answer-label answer label-5'><span class='answer'>Percent of insurance billings denied due to lack of record documentation<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75082' \/><div class='watu-question-choice'><input type='radio' name='answer-19385[]' id='answer-id-75082' class='answer answer-5 js-answer-label answerof-19385' value='75082' \/>&nbsp;<label for='answer-id-75082' id='answer-label-75082' class='js-answer-label answer label-5'><span class='answer'>Number of coder queries regarding inconsistent physician record documentation<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75083' \/><div class='watu-question-choice'><input type='radio' name='answer-19385[]' id='answer-id-75083' class='answer answer-5 js-answer-label answerof-19385' value='75083' \/>&nbsp;<label for='answer-id-75083' id='answer-label-75083' class='js-answer-label answer label-5'><span class='answer'>Results of a survey of physicians that asks about documentation practices<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75084' \/><div class='watu-question-choice'><input type='radio' name='answer-19385[]' id='answer-id-75084' class='answer answer-5 php-answer-label answerof-19385' value='75084' \/>&nbsp;<label for='answer-id-75084' id='answer-label-75084' class='php-answer-label answer label-5'><span class='answer'>Incidence of redundancies in physician notes in a sample of hospital admissions<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>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.<br\/>CDIP Exam Preparation Guide &#8211; AHIMA<br\/>Auditing Copy and Paste &#8211; AHIMA<br\/>Copy\/Paste: Prevalence, Problems, and Best Practices &#8211; AHIMA<br\/>Documentation Denials: How to Avoid Them &#8211; AAPC<br\/>[Q&amp;A: Querying for clinical validation | ACDIS]<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(5,this)' id='btn-5' value='See Answer'  \/><input type='hidden' id='questionType5' value='radio' class=''><\/div><div class='watu-question' id='question-6'><div class='question-content'><p><strong>NEW QUESTION 32<\/strong><br \/>When a change in departmental workflow is necessary, the first step is to<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19386' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75085' \/><div class='watu-question-choice'><input type='radio' name='answer-19386[]' id='answer-id-75085' class='answer answer-6 js-answer-label answerof-19386' value='75085' \/>&nbsp;<label for='answer-id-75085' id='answer-label-75085' class='js-answer-label answer label-6'><span class='answer'>define the gaps and solutions<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75086' \/><div class='watu-question-choice'><input type='radio' name='answer-19386[]' id='answer-id-75086' class='answer answer-6 js-answer-label answerof-19386' value='75086' \/>&nbsp;<label for='answer-id-75086' id='answer-label-75086' class='js-answer-label answer label-6'><span class='answer'>set realistic timelines<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75087' \/><div class='watu-question-choice'><input type='radio' name='answer-19386[]' id='answer-id-75087' class='answer answer-6 js-answer-label answerof-19386' value='75087' \/>&nbsp;<label for='answer-id-75087' id='answer-label-75087' class='js-answer-label answer label-6'><span class='answer'>re-engineer the process<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75088' \/><div class='watu-question-choice'><input type='radio' name='answer-19386[]' id='answer-id-75088' class='answer answer-6 php-answer-label answerof-19386' value='75088' \/>&nbsp;<label for='answer-id-75088' id='answer-label-75088' class='php-answer-label answer label-6'><span class='answer'>assess the current workflow<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>The first step in changing a departmental workflow is to assess the current workflow and identify the problems or inefficiencies that need to be addressed. This will help to define the gaps and solutions, set realistic timelines, and re-engineer the process.<br\/>References: AHIMA. &#8220;CDIP Exam Preparation.&#8221; AHIMA Press, Chicago, IL, 2017: 125-126.<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(6,this)' id='btn-6' value='See Answer'  \/><input type='hidden' id='questionType6' value='radio' class=''><\/div><div class='watu-question' id='question-7'><div class='question-content'><p><strong>NEW QUESTION 33<\/strong><br \/>Proposed changes to the inpatient prospective payment system (IPPS) take effect on<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19387' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75089' \/><div class='watu-question-choice'><input type='radio' name='answer-19387[]' id='answer-id-75089' class='answer answer-7 php-answer-label answerof-19387' value='75089' \/>&nbsp;<label for='answer-id-75089' id='answer-label-75089' class='php-answer-label answer label-7'><span class='answer'>October 1<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75090' \/><div class='watu-question-choice'><input type='radio' name='answer-19387[]' id='answer-id-75090' class='answer answer-7 js-answer-label answerof-19387' value='75090' \/>&nbsp;<label for='answer-id-75090' id='answer-label-75090' class='js-answer-label answer label-7'><span class='answer'>January 1<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75091' \/><div class='watu-question-choice'><input type='radio' name='answer-19387[]' id='answer-id-75091' class='answer answer-7 js-answer-label answerof-19387' value='75091' \/>&nbsp;<label for='answer-id-75091' id='answer-label-75091' class='js-answer-label answer label-7'><span class='answer'>July 1<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75092' \/><div class='watu-question-choice'><input type='radio' name='answer-19387[]' id='answer-id-75092' class='answer answer-7 js-answer-label answerof-19387' value='75092' \/>&nbsp;<label for='answer-id-75092' id='answer-label-75092' class='js-answer-label answer label-7'><span class='answer'>April 1<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>Proposed changes to the inpatient prospective payment system (IPPS) take effect on October 1 of each fiscal year (FY), which begins on October 1 and ends on September 30 of the next calendar year. The IPPS final rule is usually issued by the Centers for Medicare &amp; Medicaid Services (CMS) around August 1 of each year, and it updates the Medicare payment policies and rates for acute care hospitals and long-term care hospitals for the upcoming FY. The effective date of the final rule is October 1, unless otherwise specified by CMS 2.<br\/>References: 1: Inpatient Prospective Payment System (IPPS) 2023 Final Rule Summary of &#8230; 3 2: Acute Inpatient PPS | CMS 1<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(7,this)' id='btn-7' value='See Answer'  \/><input type='hidden' id='questionType7' value='radio' class=''><\/div><div class='watu-question' id='question-8'><div class='question-content'><p><strong>NEW QUESTION 34<\/strong><br \/>Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19388' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75093' \/><div class='watu-question-choice'><input type='radio' name='answer-19388[]' id='answer-id-75093' class='answer answer-8 js-answer-label answerof-19388' value='75093' \/>&nbsp;<label for='answer-id-75093' id='answer-label-75093' class='js-answer-label answer label-8'><span class='answer'>Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75094' \/><div class='watu-question-choice'><input type='radio' name='answer-19388[]' id='answer-id-75094' class='answer answer-8 js-answer-label answerof-19388' value='75094' \/>&nbsp;<label for='answer-id-75094' id='answer-label-75094' class='js-answer-label answer label-8'><span class='answer'>Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75095' \/><div class='watu-question-choice'><input type='radio' name='answer-19388[]' id='answer-id-75095' class='answer answer-8 php-answer-label answerof-19388' value='75095' \/>&nbsp;<label for='answer-id-75095' id='answer-label-75095' class='php-answer-label answer label-8'><span class='answer'>Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), Office of Inspector General (OIG)<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75096' \/><div class='watu-question-choice'><input type='radio' name='answer-19388[]' id='answer-id-75096' class='answer answer-8 js-answer-label answerof-19388' value='75096' \/>&nbsp;<label for='answer-id-75096' id='answer-label-75096' class='js-answer-label answer label-8'><span class='answer'>Center for Improvement in Healthcare (CIHQ), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>The organizations that a clinical documentation integrity practitioner (CDIP) should monitor are Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), and Office of Inspector General (OIG). These organizations are involved in auditing, reviewing, and investigating the accuracy, completeness, and compliance of clinical documentation, coding, billing, and reimbursement practices of hospitals and other healthcare providers. The CDIP should monitor these organizations to stay updated on their policies, guidelines, findings, recommendations, and actions that may affect the CDI program and the hospital&#8217;s performance and reputation. [3][3] References: 1:<br\/>https:\/\/www.ahima.org\/media\/owmhxbv1\/cdip_contentoutline_2023_final.pdf [3][3]:<br\/>https:\/\/my.ahima.org\/store\/product?id=67077<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(8,this)' id='btn-8' value='See Answer'  \/><input type='hidden' id='questionType8' value='radio' class=''><\/div><div class='watu-question' id='question-9'><div class='question-content'><p><strong>NEW QUESTION 35<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19389' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75097' \/><div class='watu-question-choice'><input type='radio' name='answer-19389[]' id='answer-id-75097' class='answer answer-9 js-answer-label answerof-19389' value='75097' \/>&nbsp;<label for='answer-id-75097' id='answer-label-75097' class='js-answer-label answer label-9'><span class='answer'>Record the query response as disagreed<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75098' \/><div class='watu-question-choice'><input type='radio' name='answer-19389[]' id='answer-id-75098' class='answer answer-9 js-answer-label answerof-19389' value='75098' \/>&nbsp;<label for='answer-id-75098' id='answer-label-75098' class='js-answer-label answer label-9'><span class='answer'>Have a different CDIP query the provider<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75099' \/><div class='watu-question-choice'><input type='radio' name='answer-19389[]' id='answer-id-75099' class='answer answer-9 js-answer-label answerof-19389' value='75099' \/>&nbsp;<label for='answer-id-75099' id='answer-label-75099' class='js-answer-label answer label-9'><span class='answer'>Revise the query and send it back to the provider<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75100' \/><div class='watu-question-choice'><input type='radio' name='answer-19389[]' id='answer-id-75100' class='answer answer-9 php-answer-label answerof-19389' value='75100' \/>&nbsp;<label for='answer-id-75100' id='answer-label-75100' class='php-answer-label answer label-9'><span class='answer'>Implement the department&#8217;s escalation process<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>If the provider&#8217;s response to the query is different than what was expected by the CDIP, the CDIP should implement the department&#8217;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.<br\/>A: Record the query response as disagreed. This is not a sufficient action to take if the provider&#8217;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.<br\/>B: Have a different CDI query the provider. This is not an appropriate action to take if the provider&#8217;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.<br\/>C: Revise the query and send it back to the provider. This is not a recommended action to take if the provider&#8217;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&#8217;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.<br\/>References:<br\/>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) &#8211; AHIMA The Provider Query Toolkit: A Guide to Compliant Practices<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(9,this)' id='btn-9' value='See Answer'  \/><input type='hidden' id='questionType9' value='radio' class=''><\/div><div class='watu-question' id='question-10'><div class='question-content'><p><strong>NEW QUESTION 36<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19390' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75101' \/><div class='watu-question-choice'><input type='radio' name='answer-19390[]' id='answer-id-75101' class='answer answer-10 js-answer-label answerof-19390' value='75101' \/>&nbsp;<label for='answer-id-75101' id='answer-label-75101' class='js-answer-label answer label-10'><span class='answer'>No query is needed because the patient was dehydrated<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75102' \/><div class='watu-question-choice'><input type='radio' name='answer-19390[]' id='answer-id-75102' class='answer answer-10 php-answer-label answerof-19390' value='75102' \/>&nbsp;<label for='answer-id-75102' id='answer-label-75102' class='php-answer-label answer label-10'><span class='answer'>Query the physician to see if acute renal failure is clinically supported<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75103' \/><div class='watu-question-choice'><input type='radio' name='answer-19390[]' id='answer-id-75103' class='answer answer-10 js-answer-label answerof-19390' value='75103' \/>&nbsp;<label for='answer-id-75103' id='answer-label-75103' class='js-answer-label answer label-10'><span class='answer'>Query the physician to see if acute renal failure with tubular necrosis is supported<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75104' \/><div class='watu-question-choice'><input type='radio' name='answer-19390[]' id='answer-id-75104' class='answer answer-10 js-answer-label answerof-19390' value='75104' \/>&nbsp;<label for='answer-id-75104' id='answer-label-75104' class='js-answer-label answer label-10'><span class='answer'>Code acute renal failure since symptoms are there and documented<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>The appropriate action in this case is to query the physician to see if acute renal failure is clinically supported.<br\/>This is because the patient has signs and symptoms of acute renal failure, such as oliguria, pulmonary edema, and elevated creatinine, but the diagnosis is not documented in the medical record. Acute renal failure is a clinical syndrome characterized by a rapid decline in kidney function and accumulation of metabolic waste products. It can be caused by various factors, such as dehydration, hypovolemia, sepsis, nephrotoxins, or obstruction. Acute renal failure can be classified according to the RIFLE criteria (Risk, Injury, Failure, Loss, End-stage kidney disease) or the AKIN criteria (Acute Kidney Injury Network), which are based on changes in serum creatinine and urine output 23. A query to the physician is needed to confirm or rule out the diagnosis of acute renal failure, specify the etiology and severity of the condition, and document any associated complications or comorbidities. A query to the physician will also improve the accuracy and completeness of the documentation and coding, and reflect the true clinical picture and resource utilization of the patient.<br\/>References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: Acute Kidney Injury: Diagnosis and Management | AAFP 3: AKIN Classification for Acute Kidney Injury (AKI) &#8211; MDCalc<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(10,this)' id='btn-10' value='See Answer'  \/><input type='hidden' id='questionType10' value='radio' class=''><\/div><div class='watu-question' id='question-11'><div class='question-content'><p><strong>NEW QUESTION 37<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19391' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75105' \/><div class='watu-question-choice'><input type='radio' name='answer-19391[]' id='answer-id-75105' class='answer answer-11 js-answer-label answerof-19391' value='75105' \/>&nbsp;<label for='answer-id-75105' id='answer-label-75105' class='js-answer-label answer label-11'><span class='answer'>Audit cases for missed diagnosis by the CDI practitioner to target in the education plan<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75106' \/><div class='watu-question-choice'><input type='radio' name='answer-19391[]' id='answer-id-75106' class='answer answer-11 js-answer-label answerof-19391' value='75106' \/>&nbsp;<label for='answer-id-75106' id='answer-label-75106' class='js-answer-label answer label-11'><span class='answer'>Audit focused cases by physicians that have a higher SOI\/ROM for education plan<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75107' \/><div class='watu-question-choice'><input type='radio' name='answer-19391[]' id='answer-id-75107' class='answer answer-11 js-answer-label answerof-19391' value='75107' \/>&nbsp;<label for='answer-id-75107' id='answer-label-75107' class='js-answer-label answer label-11'><span class='answer'>Audit cases that have high SOI\/ROM assigned by coders for education and follow-up<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75108' \/><div class='watu-question-choice'><input type='radio' name='answer-19391[]' id='answer-id-75108' class='answer answer-11 php-answer-label answerof-19391' value='75108' \/>&nbsp;<label for='answer-id-75108' id='answer-label-75108' class='php-answer-label answer label-11'><span class='answer'>Audit focused APR-DRGs and develop education plan for CDI team and physicians<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>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.<br\/>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&#8217;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.<br\/>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&#8217;s performance, without considering the physician&#8217;s role in documentation quality and completeness.<br\/>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.<br\/>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.<br\/>References:<br\/>CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530<br\/>3M\u2122 All Patient Refined Diagnosis Related Groups (APR DRGs) | 3M United States Q&amp;A: Understanding SOI and ROM in the APR-DRG system | ACDIS Use SOI\/ROM scores to enhance CDI program effectiveness | ACDIS<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(11,this)' id='btn-11' value='See Answer'  \/><input type='hidden' id='questionType11' value='radio' class=''><\/div><div class='watu-question' id='question-12'><div class='question-content'><p><strong>NEW QUESTION 38<\/strong><br \/>A patient&#8217;s progress note states &#8220;The patient has chronic systolic heart failure&#8221;. 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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19392' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75109' \/><div class='watu-question-choice'><input type='radio' name='answer-19392[]' id='answer-id-75109' class='answer answer-12 php-answer-label answerof-19392' value='75109' \/>&nbsp;<label for='answer-id-75109' id='answer-label-75109' class='php-answer-label answer label-12'><span class='answer'>The patient has chronic systolic heart failure.<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75110' \/><div class='watu-question-choice'><input type='radio' name='answer-19392[]' id='answer-id-75110' class='answer answer-12 js-answer-label answerof-19392' value='75110' \/>&nbsp;<label for='answer-id-75110' id='answer-label-75110' class='js-answer-label answer label-12'><span class='answer'>The patient has acute on chronic systolic heart failure.<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75111' \/><div class='watu-question-choice'><input type='radio' name='answer-19392[]' id='answer-id-75111' class='answer answer-12 js-answer-label answerof-19392' value='75111' \/>&nbsp;<label for='answer-id-75111' id='answer-label-75111' class='js-answer-label answer label-12'><span class='answer'>The patient did have an exacerbation of heart failure.<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75112' \/><div class='watu-question-choice'><input type='radio' name='answer-19392[]' id='answer-id-75112' class='answer answer-12 js-answer-label answerof-19392' value='75112' \/>&nbsp;<label for='answer-id-75112' id='answer-label-75112' class='js-answer-label answer label-12'><span class='answer'>The patient has decompensated systolic heart failure.<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement2. In this case, the CDIP queried the physician to clarify the current acuity of the diagnosis of chronic systolic heart failure, based on clinical indicators suggestive of an exacerbation of systolic heart failure. The subsequent documentation in the health record that suggests the provider did not understand the query is A. The patient has chronic systolic heart failure. This documentation does not address the query or provide any additional information about the patient&#8217;s condition. It simply repeats the same diagnosis that was already documented in the progress note. This documentation does not reflect the patient&#8217;s true severity of illness, risk of mortality, or reimbursement3. The other options are not correct because they do provide some information about the current acuity of the diagnosis of chronic systolic heart failure, such as acute on chronic, exacerbation, or decompensation. These terms indicate a higher level of severity and complexity than chronic alone. References:<br\/>CDIP Exam Preparation Guide &#8211; AHIMA<br\/>Guidelines for Achieving a Compliant Query Practice (2019 Update) &#8211; AHIMA Severity of Illness: What Is It? Why Is It Important? | HCPro<br\/>[Q&amp;A: Acute on chronic versus decompensated heart failure | ACDIS]<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(12,this)' id='btn-12' value='See Answer'  \/><input type='hidden' id='questionType12' value='radio' class=''><\/div><div class='watu-question' id='question-13'><div class='question-content'><p><strong>NEW QUESTION 39<\/strong><br \/>When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19393' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75113' \/><div class='watu-question-choice'><input type='radio' name='answer-19393[]' id='answer-id-75113' class='answer answer-13 js-answer-label answerof-19393' value='75113' \/>&nbsp;<label for='answer-id-75113' id='answer-label-75113' class='js-answer-label answer label-13'><span class='answer'>code the first condition listed<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75114' \/><div class='watu-question-choice'><input type='radio' name='answer-19393[]' id='answer-id-75114' class='answer answer-13 js-answer-label answerof-19393' value='75114' \/>&nbsp;<label for='answer-id-75114' id='answer-label-75114' class='js-answer-label answer label-13'><span class='answer'>query for clarification<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75115' \/><div class='watu-question-choice'><input type='radio' name='answer-19393[]' id='answer-id-75115' class='answer answer-13 js-answer-label answerof-19393' value='75115' \/>&nbsp;<label for='answer-id-75115' id='answer-label-75115' class='js-answer-label answer label-13'><span class='answer'>not code either diagnosis<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75116' \/><div class='watu-question-choice'><input type='radio' name='answer-19393[]' id='answer-id-75116' class='answer answer-13 php-answer-label answerof-19393' value='75116' \/>&nbsp;<label for='answer-id-75116' id='answer-label-75116' class='php-answer-label answer label-13'><span class='answer'>code both diagnoses<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>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&#8217;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: :<br\/>https:\/\/www.ahima.org\/media\/owmhxbv1\/cdip_contentoutline_2023_final.pdf :<br\/>https:\/\/my.ahima.org\/store\/product?id=67077<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(13,this)' id='btn-13' value='See Answer'  \/><input type='hidden' id='questionType13' value='radio' class=''><\/div><div class='watu-question' id='question-14'><div class='question-content'><p><strong>NEW QUESTION 40<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19394' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75117' \/><div class='watu-question-choice'><input type='radio' name='answer-19394[]' id='answer-id-75117' class='answer answer-14 js-answer-label answerof-19394' value='75117' \/>&nbsp;<label for='answer-id-75117' id='answer-label-75117' class='js-answer-label answer label-14'><span class='answer'>Multiple-choice<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75118' \/><div class='watu-question-choice'><input type='radio' name='answer-19394[]' id='answer-id-75118' class='answer answer-14 js-answer-label answerof-19394' value='75118' \/>&nbsp;<label for='answer-id-75118' id='answer-label-75118' class='js-answer-label answer label-14'><span class='answer'>Open-ended<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75119' \/><div class='watu-question-choice'><input type='radio' name='answer-19394[]' id='answer-id-75119' class='answer answer-14 js-answer-label answerof-19394' value='75119' \/>&nbsp;<label for='answer-id-75119' id='answer-label-75119' class='js-answer-label answer label-14'><span class='answer'>Verbal<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75120' \/><div class='watu-question-choice'><input type='radio' name='answer-19394[]' id='answer-id-75120' class='answer answer-14 php-answer-label answerof-19394' value='75120' \/>&nbsp;<label for='answer-id-75120' id='answer-label-75120' class='php-answer-label answer label-14'><span class='answer'>Yes\/No<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>A yes\/no 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 because it may lead to leading or suggesting a diagnosis that is not supported by the provider&#8217;s documentation. A yes\/no query should only be used when there is clear and consistent documentation of a condition\/diagnosis in the health record, and the query is seeking confirmation or denial of a specific fact or detail related to that condition\/diagnosis. A multiple-choice, open-ended, or verbal query may be more appropriate to allow the provider to choose from a list of possible diagnoses, provide additional information, or explain the clinical reasoning behind the documentation. (CDIP Exam Preparation Guide) References:<br\/>CDIP Exam Content Outline1<br\/>CDIP Exam Preparation Guide2<br\/>AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(14,this)' id='btn-14' value='See Answer'  \/><input type='hidden' id='questionType14' value='radio' class=''><\/div><div class='watu-question' id='question-15'><div class='question-content'><p><strong>NEW QUESTION 41<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19395' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75121' \/><div class='watu-question-choice'><input type='radio' name='answer-19395[]' id='answer-id-75121' class='answer answer-15 js-answer-label answerof-19395' value='75121' \/>&nbsp;<label for='answer-id-75121' id='answer-label-75121' class='js-answer-label answer label-15'><span class='answer'>Update medical records with unsigned physician responses<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75122' \/><div class='watu-question-choice'><input type='radio' name='answer-19395[]' id='answer-id-75122' class='answer answer-15 js-answer-label answerof-19395' value='75122' \/>&nbsp;<label for='answer-id-75122' id='answer-label-75122' class='js-answer-label answer label-15'><span class='answer'>Allow physician responses via e-mail<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75123' \/><div class='watu-question-choice'><input type='radio' name='answer-19395[]' id='answer-id-75123' class='answer answer-15 php-answer-label answerof-19395' value='75123' \/>&nbsp;<label for='answer-id-75123' id='answer-label-75123' class='php-answer-label answer label-15'><span class='answer'>Provide education to physicians on query process<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75124' \/><div class='watu-question-choice'><input type='radio' name='answer-19395[]' id='answer-id-75124' class='answer answer-15 js-answer-label answerof-19395' value='75124' \/>&nbsp;<label for='answer-id-75124' id='answer-label-75124' class='js-answer-label answer label-15'><span class='answer'>Require the CDIP to call physicians to follow up<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>According to the AHIMA\/ACDIS Query Practice Brief, one of the best practices for a compliant query process is to provide ongoing education to physicians on the importance of documentation integrity, the query process, and the impact of documentation on quality measures, reimbursement, and compliance1. Education can help physicians understand the rationale and expectations for responding to queries, as well as the benefits of accurate and complete documentation for patient care and data quality. Education can also address any barriers or challenges that physicians may face in responding to queries, such as time constraints, technology issues, or workflow preferences1. References:<br\/>AHIMA\/ACDIS Query Practice Brief &#8211; Updated 12\/2022<br\/>Guidelines for Achieving a Compliant Query Practice (2019 Update) &#8211; AHIMA<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(15,this)' id='btn-15' value='See Answer'  \/><input type='hidden' id='questionType15' value='radio' class=''><\/div><div class='watu-question' id='question-16'><div class='question-content'><p><strong>NEW QUESTION 42<\/strong><br \/>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.<br \/>What is the BEST next step?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19396' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75125' \/><div class='watu-question-choice'><input type='radio' name='answer-19396[]' id='answer-id-75125' class='answer answer-16 js-answer-label answerof-19396' value='75125' \/>&nbsp;<label for='answer-id-75125' id='answer-label-75125' class='js-answer-label answer label-16'><span class='answer'>Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75126' \/><div class='watu-question-choice'><input type='radio' name='answer-19396[]' id='answer-id-75126' class='answer answer-16 js-answer-label answerof-19396' value='75126' \/>&nbsp;<label for='answer-id-75126' id='answer-label-75126' class='js-answer-label answer label-16'><span class='answer'>Appeal the denial because all payors must use the hospital&#8217;s sepsis criteria when reviewing their claims.<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75127' \/><div class='watu-question-choice'><input type='radio' name='answer-19396[]' id='answer-id-75127' class='answer answer-16 js-answer-label answerof-19396' value='75127' \/>&nbsp;<label for='answer-id-75127' id='answer-label-75127' class='js-answer-label answer label-16'><span class='answer'>Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75128' \/><div class='watu-question-choice'><input type='radio' name='answer-19396[]' id='answer-id-75128' class='answer answer-16 php-answer-label answerof-19396' value='75128' \/>&nbsp;<label for='answer-id-75128' id='answer-label-75128' class='php-answer-label answer label-16'><span class='answer'>Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'><\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(16,this)' id='btn-16' value='See Answer'  \/><input type='hidden' id='questionType16' value='radio' class=''><\/div><div class='watu-question' id='question-17'><div class='question-content'><p><strong>NEW QUESTION 43<\/strong><br \/>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&#8217;s Guidelines for Achieving a Compliant Query Practice?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19397' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75129' \/><div class='watu-question-choice'><input type='radio' name='answer-19397[]' id='answer-id-75129' class='answer answer-17 js-answer-label answerof-19397' value='75129' \/>&nbsp;<label for='answer-id-75129' id='answer-label-75129' class='js-answer-label answer label-17'><span class='answer'>Complete the documentation immediately after the provider&#8217;s response<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75130' \/><div class='watu-question-choice'><input type='radio' name='answer-19397[]' id='answer-id-75130' class='answer answer-17 js-answer-label answerof-19397' value='75130' \/>&nbsp;<label for='answer-id-75130' id='answer-label-75130' class='js-answer-label answer label-17'><span class='answer'>Complete the documentation at the end of the day when entering cases reviewed<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75131' \/><div class='watu-question-choice'><input type='radio' name='answer-19397[]' id='answer-id-75131' class='answer answer-17 js-answer-label answerof-19397' value='75131' \/>&nbsp;<label for='answer-id-75131' id='answer-label-75131' class='js-answer-label answer label-17'><span class='answer'>Complete the documentation when there is a provider agreement<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75132' \/><div class='watu-question-choice'><input type='radio' name='answer-19397[]' id='answer-id-75132' class='answer answer-17 php-answer-label answerof-19397' value='75132' \/>&nbsp;<label for='answer-id-75132' id='answer-label-75132' class='php-answer-label answer label-17'><span class='answer'>Complete the documentation at the time of discussion or immediately following<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>According to AHIMA&#8217;s Guidelines for Achieving a Compliant Query Practice, the clinical documentation integrity practitioner (CDIP) should complete the documentation at the time of discussion or immediately following to avoid a compliance risk for this follow up failure. This is because verbal queries are considered part of the health record and must be documented in a timely and accurate manner to reflect the provider&#8217;s response and any changes in documentation or coding. Completing the documentation later or only when there is an agreement may result in errors, omissions, inconsistencies, or delays that may affect the quality and integrity of the health record and the query process. (AHIMA Guidelines for Achieving a Compliant Query Practice1) References:<br\/>AHIMA Guidelines for Achieving a Compliant Query Practice1<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(17,this)' id='btn-17' value='See Answer'  \/><input type='hidden' id='questionType17' value='radio' class=''><\/div><div class='watu-question' id='question-18'><div class='question-content'><p><strong>NEW QUESTION 44<\/strong><br \/>A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician&#8217;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.<br \/>Discharge diagnoses:<br \/>1. Pneumonia<br \/>2. COPD<br \/>3. Current smoker<br \/>What is the correct diagnostic related group assignment?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19398' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75133' \/><div class='watu-question-choice'><input type='radio' name='answer-19398[]' id='answer-id-75133' class='answer answer-18 php-answer-label answerof-19398' value='75133' \/>&nbsp;<label for='answer-id-75133' id='answer-label-75133' class='php-answer-label answer label-18'><span class='answer'>DRG 190 Chronic Obstructive Pulmonary Disease with MCC<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75134' \/><div class='watu-question-choice'><input type='radio' name='answer-19398[]' id='answer-id-75134' class='answer answer-18 js-answer-label answerof-19398' value='75134' \/>&nbsp;<label for='answer-id-75134' id='answer-label-75134' class='js-answer-label answer label-18'><span class='answer'>DRG 202 Bronchitis and Asthma with CC\/MCC<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75135' \/><div class='watu-question-choice'><input type='radio' name='answer-19398[]' id='answer-id-75135' class='answer answer-18 js-answer-label answerof-19398' value='75135' \/>&nbsp;<label for='answer-id-75135' id='answer-label-75135' class='js-answer-label answer label-18'><span class='answer'>DRG 204 Respiratory Signs and Symptoms<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75136' \/><div class='watu-question-choice'><input type='radio' name='answer-19398[]' id='answer-id-75136' class='answer answer-18 js-answer-label answerof-19398' value='75136' \/>&nbsp;<label for='answer-id-75136' id='answer-label-75136' class='js-answer-label answer label-18'><span class='answer'>DRG 194 Simple Pneumonia and Pleurisy without CC\/MCC<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>According to the ICD-10-CM\/PCS MS-DRG Definitions Manual, DRG 190 is assigned for patients with a principal diagnosis of chronic obstructive pulmonary disease (COPD) and a major complication or comorbidity (MCC)1. Pneumonia is considered an MCC for this DRG2. Therefore, the patient in this case meets the criteria for DRG 190. The other options are incorrect because they do not match the principal diagnosis or the MCC of the patient.<br\/>ICD-10-CM\/PCS MS-DRG Definitions Manual<br\/>ICD-10-CM\/PCS MS-DRG v38.0 Definitions Manual &#8211; MDC 4: Diseases and Disorders of the Respiratory System<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(18,this)' id='btn-18' value='See Answer'  \/><input type='hidden' id='questionType18' value='radio' class=''><\/div><div class='watu-question' id='question-19'><div class='question-content'><p><strong>NEW QUESTION 45<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19399' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75137' \/><div class='watu-question-choice'><input type='radio' name='answer-19399[]' id='answer-id-75137' class='answer answer-19 js-answer-label answerof-19399' value='75137' \/>&nbsp;<label for='answer-id-75137' id='answer-label-75137' class='js-answer-label answer label-19'><span class='answer'>Expand the CDI program to larger areas in outpatient clinics<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75138' \/><div class='watu-question-choice'><input type='radio' name='answer-19399[]' id='answer-id-75138' class='answer answer-19 js-answer-label answerof-19399' value='75138' \/>&nbsp;<label for='answer-id-75138' id='answer-label-75138' class='js-answer-label answer label-19'><span class='answer'>Prioritize to focus on efforts with the largest return on investment<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75139' \/><div class='watu-question-choice'><input type='radio' name='answer-19399[]' id='answer-id-75139' class='answer answer-19 js-answer-label answerof-19399' value='75139' \/>&nbsp;<label for='answer-id-75139' id='answer-label-75139' class='js-answer-label answer label-19'><span class='answer'>Identify key metrics to develop program measures for coders<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75140' \/><div class='watu-question-choice'><input type='radio' name='answer-19399[]' id='answer-id-75140' class='answer answer-19 php-answer-label answerof-19399' value='75140' \/>&nbsp;<label for='answer-id-75140' id='answer-label-75140' class='php-answer-label answer label-19'><span class='answer'>Establish a CDI steering committee to build a strong foundation<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>A CDI steering committee is a group of interdisciplinary leaders who oversee and guide the CDI program&#8217;s objectives, outcomes, and metrics. The committee should include representatives from finance, clinical, coding, quality, and other areas that are impacted by CDI. The committee should meet regularly to review the CDI program&#8217;s performance, identify opportunities for improvement, and provide support and education to the CDI staff and providers. A CDI steering committee can help reinvigorate a stagnant CDI program by ensuring that it aligns with the organization&#8217;s vision and mission, addresses the current challenges and needs, and fosters collaboration and communication among stakeholders. The other options are not necessarily effective ways to reinvigorate a CDI program. Expanding the CDI program to larger areas in outpatient clinics may not be feasible or appropriate without a clear strategy and plan. Prioritizing to focus on efforts with the largest return on investment may not reflect the true value and quality of the CDI program. Identifying key metrics to develop program measures for coders may not capture the full scope and impact of the CDI program.<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(19,this)' id='btn-19' value='See Answer'  \/><input type='hidden' id='questionType19' value='radio' class=''><\/div><div class='watu-question' id='question-20'><div class='question-content'><p><strong>NEW QUESTION 46<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19400' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75141' \/><div class='watu-question-choice'><input type='radio' name='answer-19400[]' id='answer-id-75141' class='answer answer-20 js-answer-label answerof-19400' value='75141' \/>&nbsp;<label for='answer-id-75141' id='answer-label-75141' class='js-answer-label answer label-20'><span class='answer'>Look for wound care documentation<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75142' \/><div class='watu-question-choice'><input type='radio' name='answer-19400[]' id='answer-id-75142' class='answer answer-20 js-answer-label answerof-19400' value='75142' \/>&nbsp;<label for='answer-id-75142' id='answer-label-75142' class='js-answer-label answer label-20'><span class='answer'>Read the nursing admission notes<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75143' \/><div class='watu-question-choice'><input type='radio' name='answer-19400[]' id='answer-id-75143' class='answer answer-20 js-answer-label answerof-19400' value='75143' \/>&nbsp;<label for='answer-id-75143' id='answer-label-75143' class='js-answer-label answer label-20'><span class='answer'>Query the attending provider<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75144' \/><div class='watu-question-choice'><input type='radio' name='answer-19400[]' id='answer-id-75144' class='answer answer-20 php-answer-label answerof-19400' value='75144' \/>&nbsp;<label for='answer-id-75144' id='answer-label-75144' class='php-answer-label answer label-20'><span class='answer'>Review the history and physical<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>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&amp;P) because it is the initial source of information about the patient&#8217;s condition at the time of admission. The H&amp;P should include a comprehensive physical examination that covers all body systems, including the skin. If the H&amp;P documents the presence of a stage IV sacral decubitus ulcer, then the POA status is &#8220;yes&#8221;. If the H&amp;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:<br\/>CDIP Exam Content Outline1<br\/>CDIP Exam Preparation Guide2<br\/>Present on Admission Reporting Guidelines3<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(20,this)' id='btn-20' value='See Answer'  \/><input type='hidden' id='questionType20' value='radio' class=''><\/div><div class='watu-question' id='question-21'><div class='question-content'><p><strong>NEW QUESTION 47<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19401' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75145' \/><div class='watu-question-choice'><input type='radio' name='answer-19401[]' id='answer-id-75145' class='answer answer-21 js-answer-label answerof-19401' value='75145' \/>&nbsp;<label for='answer-id-75145' id='answer-label-75145' class='js-answer-label answer label-21'><span class='answer'>Schedule a group meeting with all physicians<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75146' \/><div class='watu-question-choice'><input type='radio' name='answer-19401[]' id='answer-id-75146' class='answer answer-21 js-answer-label answerof-19401' value='75146' \/>&nbsp;<label for='answer-id-75146' id='answer-label-75146' class='js-answer-label answer label-21'><span class='answer'>Schedule individual meetings with each physician<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75147' \/><div class='watu-question-choice'><input type='radio' name='answer-19401[]' id='answer-id-75147' class='answer answer-21 php-answer-label answerof-19401' value='75147' \/>&nbsp;<label for='answer-id-75147' id='answer-label-75147' class='php-answer-label answer label-21'><span class='answer'>Schedule individual meetings with each low-performing physician<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75148' \/><div class='watu-question-choice'><input type='radio' name='answer-19401[]' id='answer-id-75148' class='answer answer-21 js-answer-label answerof-19401' value='75148' \/>&nbsp;<label for='answer-id-75148' id='answer-label-75148' class='js-answer-label answer label-21'><span class='answer'>Schedule a meeting with the chair of the gastroenterology department<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>According to the ACDIS Practice Brief, a query escalation policy should describe how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. 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 level. The policies should reflect a method of response that can realistically occur for the organization1. In this case, since two physicians have significantly lower query response rates than the target, the CDI physician advisor\/champion should schedule individual meetings with each low-performing physician to provide feedback, education, and support. A group meeting with all physicians may not be effective or efficient, as it may not address the specific barriers or challenges faced by the low-performing physicians. A meeting with the chair of the gastroenterology department may be helpful, but it may not be sufficient to resolve the issue without direct communication with the low-performing physicians.<br\/>References:<br\/>CDI Week 2020 Q&amp;A: CDI and key performance indicators1<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(21,this)' id='btn-21' value='See Answer'  \/><input type='hidden' id='questionType21' value='radio' class=''><\/div><div class='watu-question' id='question-22'><div class='question-content'><p><strong>NEW QUESTION 48<\/strong><br \/>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?<\/p>\n<\/div><input type='hidden' name='question_id[]' value='19402' \/><div class='watu-questions-wrap '><input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75149' \/><div class='watu-question-choice'><input type='radio' name='answer-19402[]' id='answer-id-75149' class='answer answer-22 php-answer-label answerof-19402' value='75149' \/>&nbsp;<label for='answer-id-75149' id='answer-label-75149' class='php-answer-label answer label-22'><span class='answer'>61154 Burr hole(s) with evacuation and\/or drainage of hematoma, extradural or subdural<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75150' \/><div class='watu-question-choice'><input type='radio' name='answer-19402[]' id='answer-id-75150' class='answer answer-22 js-answer-label answerof-19402' value='75150' \/>&nbsp;<label for='answer-id-75150' id='answer-label-75150' class='js-answer-label answer label-22'><span class='answer'>61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and\/or drainage of subdural hematoma<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75151' \/><div class='watu-question-choice'><input type='radio' name='answer-19402[]' id='answer-id-75151' class='answer answer-22 js-answer-label answerof-19402' value='75151' \/>&nbsp;<label for='answer-id-75151' id='answer-label-75151' class='js-answer-label answer label-22'><span class='answer'>61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion<\/span><\/label><\/div>\n<input type='hidden' name='answer_ids[]' class='watu-answer-ids' value='75152' \/><div class='watu-question-choice'><input type='radio' name='answer-19402[]' id='answer-id-75152' class='answer answer-22 js-answer-label answerof-19402' value='75152' \/>&nbsp;<label for='answer-id-75152' id='answer-label-75152' class='js-answer-label answer label-22'><span class='answer'>61105 Twist drill hole subdural\/ventricular puncture<\/span><\/label><\/div>\n<\/div><div class='show-question-feedback' style='display:none;'>Explanation<br\/>According to the CPT code description, 61154 is the appropriate code for a burr hole procedure for evacuation of a subdural hematoma. A burr hole is a small hole made in the skull with a surgical drill to access the brain or its coverings2. A subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, which are two of the three layers that cover the brain3. The evacuation of the hematoma involves removing the clot and relieving the pressure on the brain. The other codes are not applicable for this procedure because they describe different methods of access (twist drill hole) or different purposes (biopsy or puncture)4.<br\/>References:<br\/>CDI Week 2020 Q&amp;A: CDI and key performance indicators1<br\/>Mayo Clinic: Burr hole2<br\/>MedlinePlus: Subdural hematoma3<br\/>CPT Code Book 20234<\/div><input type='button' class='showchecked' style='margin: 10px 0;' onclick='showanswer1(22,this)' id='btn-22' value='See Answer'  \/><input type='hidden' id='questionType22' value='radio' class=''><\/div><div style='display:none' id='question-23'><br \/><div class='question-content'><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/blog.topexamcollection.com\/wp-content\/plugins\/watu\/loading.gif\" width=\"16\" height=\"16\" alt=\"Loading ...\" title=\"Loading ...\" \/>&nbsp;Loading &#8230;<\/div><\/div><br \/>\n<input type=\"button\" name=\"action\" onclick=\"Watu.submitResult()\" id=\"action-button\" style=\"margin:0 auto 20px auto;\" value=\"View Results\"  class=\"watu-submit-button\" \/>\n<input type=\"hidden\" name=\"no_ajax\" value=\"0\"><input type=\"hidden\" name=\"quiz_id\" value=\"983\" \/>\n<input type=\"hidden\" id=\"watuStartTime\" name=\"start_time\" value=\"2026-09-24 02:02:29\" \/>\n<\/form>\n<\/div>\n<div id=\"watu-loading-result\" style=\"display:none;\">\n\t<p align=\"center\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/blog.topexamcollection.com\/wp-content\/plugins\/watu\/loading.gif\" width=\"16\" height=\"16\" alt=\"Loading\" title=\"Loading\" \/><\/p>\n<\/div>\t\n<script type=\"text\/javascript\">\nvar exam_id=0;\nvar question_ids='';\nvar watuURL='';\njQuery(function($){\nquestion_ids = \"19381,19382,19383,19384,19385,19386,19387,19388,19389,19390,19391,19392,19393,19394,19395,19396,19397,19398,19399,19400,19401,19402\";\nexam_id = 983;\nWatu.exam_id = exam_id;\nWatu.qArr = question_ids.split(',');\nWatu.post_id = 2398;\nWatu.singlePage = '1';\nWatu.hAppID = \"0.22410600 1790215349\";\nwatuURL = \"https:\/\/blog.topexamcollection.com\/wp-admin\/admin-ajax.php\";\nWatu.noAlertUnanswered = 0;\n});\n\nfunction showanswer1(e,q) {\n\tvar check = new Array();\n\tjQuery('.answer-' + e).each(function (i) {\n\t\tcheck.push(this.checked)\n\t})\n\tlet textval = jQuery('.watu-textarea-' + e).val()\n\tif (jQuery.inArray(true, check) >= 0 || textval !== '' && textval !== undefined) {\n\t\tjQuery(q).stop().fadeOut(300)\n\t\tjQuery('.php-answer-label.label-' + e).addClass(\n\t\t\t'correct-answer'\n\t\t)\n\t\tjQuery('.answer-' + e).each(function (i) {\n\t\t\tif (this.checked && this.className.match(\/js\\-answer\/)) {\n\t\t\t\tvar number = this.id.toString().replace(\/\\D\/g, '')\n\t\t\t\tif (number) {\n\t\t\t\t\tjQuery('#answer-label-' + number).addClass('user-answer')\n\t\t\t\t}\n\t\t\t}\n\t\t})\n\t\tjQuery(q).siblings('.show-question-feedback').stop().fadeIn(300)\n\t\ttextval = ''\n\t} else if (textval == '' || textval == undefined){\n\t\t\/\/jQuery(\".hint\").stop().fadeIn(300)\n\t\talert('Please first answer the question');\n\t}\n}\nvar btnisshow = jQuery(\".php-answer-label\").length\nif (btnisshow > 0) {\n\tjQuery('.showchecked').show()\n} else {\n\tjQuery('.showchecked').hide()\n}\n<\/script>\n<p><strong>Earn Quick And Easy Success With CDIP Dumps: <a href=\"https:\/\/www.topexamcollection.com\/CDIP-vce-collection.html\" target=\"_blank\">https:\/\/www.topexamcollection.com\/CDIP-vce-collection.html<\/a><\/strong><\/p>\n\n","protected":false},"excerpt":{"rendered":"<p>CDIP Dumps By Pros &#8211; 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