CDIP 100% Pass Guaranteed Download AHIMA CDI Exam PDF Q&A [Q66-Q86]

Q66. An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?

Send a clinical validation query for only the diagnosis of sepsis.

Send a clinical validation query for both the diagnoses of sepsis and UTI.

A clinical validation query is not required for either diagnosis.

Send a clinical validation query for only the diagnosis of UTI.

Q67. The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?

Have CDI manager teaming with coding supervisor to monitor physician responses

Require physicians to document responses in charts

Permit CDI practitioners to document physician responses in the charts

Allow physician to respond via e-mail

Q68. Which of the following is used to measure the impact of a clinical documentation integrity (CDI) program on Centers for Medicare and Medicaid Services quality performance?

Risk of mortality

Case mix index

Severity of illness

Outcome measures

Q69. The key component of the auditing and monitoring process to ensure provider query response is to

audit individual providers to indicate improvement in health record documentation

have a process in place for ongoing education and training of the staff involved in conducting provider queries

make sure that the language in the query is not leading or otherwise inappropriate

review queries retrospectively to ensure that they are completed according to documented Policies and procedures

Q70. 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.

Q71. A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?

Queries are limited to non-leading questions

Non-responses to written queries are grounds for discipline

Primary care physicians must answer written queries

Queries for illegible chart notes are unnecessary

Q72. A clinical documentation integrity practitioner (CDIP) has been successful in getting physicians to respond to queries. However, when the CDIP poses a query to a specific doctor, there is no response at all. The CDIP has tried face-to-face conversations, calling, emails, texts, but still gets no response. What is the next step the CDIP should take?

Elevate the issue to the physician advisor/champion after the CDI supervisor has reviewed the case and deemed the query appropriate

Report the doctor to the Vice President of Medical Affairs so the doctor understands the importance of clinical documentation

Hold a meeting with the CDI director and the doctor to find out why the doctor is not responding to the queries

Warn the other CDIPs that the doctor is a non-responder and to forego querying

Q73. Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?

Reporting and the use of technology

Value and mission statements

Benchmarks and case mix index

Diagnostic related groups and revenue cycle

Q74. Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

Neither of the codes can be assigned

Two codes can be used together to completely describe the condition

Only one code can be assigned to completely describe the condition

This is not a convention found in ICD-10-CM

Q75. The BEST place for the provider to document a query response is which of the following?

The query form

The next progress note and the problem list

The next progress note and all subsequent notes including the discharge summary

An addendum to the history and physical

Q76. A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?

Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add ‘morbid obesity with BMI 42 kg/m2’ to your next progress note.

Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add ‘morbid obesity with BMI 42 kg/m2’ to your next progress note.

Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient’s morbid obesity was present on admission and add the diagnosis to future progress notes?

Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)

Q77. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?

DRG

OCE

NOS

NEC

Q78. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient’s severity of illness (SOI) and risk of mortality (ROM)?

Query the physician to clarify if CXR result means patient has pneumonia.

Query the physician to clarify for type of COPD such as severe asthma.

Query the physician to clarify for clinical significance of the CXR results.

Query the physician to clarify if patient has acute COPD exacerbation.

Q79. A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs:
BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia.
Aspiration precautions and IV Clindamycin
ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.

Simple pneumonia

Aspiration pneumonia

Pneumonia, a sequela of CVA

Complex pneumonia

Q80. The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

look for documented conditions that have well supported accompanying clinical criteria

determine if only the treatment is documented and there is no diagnosis documented

watch for reportable conditions or conditions that are unambiguous or otherwise complete

identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis

Q81. In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?

The latest Medicare Provider and Analysis Review data

Emphasize the Medicare requirements for documentation

Examples from the hospital’s actual cases

Explanations on how severity of illness and risk of mortality impact reimbursement

Q82. 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

Q83. Which of the following individuals is the first line of escalation for an unanswered query?

CDI Manager

CDI Steering Committee

Medical Director

HIM/Coding Manager

Q84. Which entity has the following regulation?
A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

Centers for Medicare & Medicaid Services

Office for Civil Rights

Office of the National Coordinator for Health Information Technology

Office of Inspector General

Q85. Whether or not queries should be kept as a permanent part of the medical record is decided by

physician preference

state law

federal law

organizational policy

Q86. The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?

Expand use of coding queries by CDI team

Add a physician advisor/champion to the CDI team

Encourage physician-nurse cooperation

Alter the physician documentation requirements