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| Section | Weight | Objectives |
|---|---|---|
| Education and Leadership Development | 21–26% | - CDI program leadership and organizational collaboration - CDI project development and physician engagement - Provider education and interdisciplinary communication |
| CDI Metrics and Statistics | - Performance metrics and reporting - Quality and outcome measurement (SOI/ROM) | |
| Record Review and Document Clarification | 24–28% | - Post-discharge review and documentation validation - Provider query development and compliance - Clinical documentation review and gap identification |
| Compliance | - Regulatory compliance and ethical documentation practices - Audit readiness and documentation integrity standards | |
| Clinical Coding Practice | 15–18% | - Diagnosis and procedure code assignment and sequencing - DRG assignment and reimbursement concepts - Coding fundamentals and guidelines application |
Question 1
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?
A. Warn the other CDIPs that the doctor is a non-responder and to forego querying
B. Elevate the issue to the physician advisor/champion after the CDI supervisor has reviewed the case and deemed the query appropriate
C. Hold a meeting with the CDI director and the doctor to find out why the doctor is not responding to the queries
D. Report the doctor to the Vice President of Medical Affairs so the doctor understands the importance of clinical documentation
Question 2
A key physician approaches the director of the coding department about the new emphasis associated with clinical documentation integrity (CDI). The physician does not support the program and believes the initiative will encourage inappropriate billing.
How should the director respond to the concerns?
A. Involve the physician advisor/champion in addressing the medical staff's concerns
B. Inform the physician that changes must be made
C. Develop an administrative panel to oversee CDI process
D. Refer the physician to the finance department to discuss required billing changes
Question 3
Which of the following is the definition of an Excludes 2 note in ICD-10-CM?
A. Only one code can be assigned to completely describe the condition
B. Two codes can be used together to completely describe the condition
C. Neither of the codes can be assigned
D. This is not a convention found in ICD-10-CM
Question 4
Creating policies and procedures for the query process will help eliminate
A. indecision
B. risk
C. confusion
D. duplication
Question 5
What policies should query professionals follow?
A. CMS's policies related to querying
B. All healthcare entity's policies are the same
C. AHIMA's policies related to querying
D. Their healthcare entity's internal policies related to querying
Solutions:
| Question 1 Answer: B | Question 2 Answer: A | Question 3 Answer: B | Question 4 Answer: C | Question 5 Answer: D |
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