AHIMA CDIP EXAM | CDIP WELL PREP - ASSIST YOU CLEAR CDIP: CERTIFIED DOCUMENTATION INTEGRITY PRACTITIONER EXAM

AHIMA CDIP Exam | CDIP Well Prep - Assist you Clear CDIP: Certified Documentation Integrity Practitioner Exam

AHIMA CDIP Exam | CDIP Well Prep - Assist you Clear CDIP: Certified Documentation Integrity Practitioner Exam

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AHIMA Certified Documentation Integrity Practitioner Sample Questions (Q47-Q52):

NEW QUESTION # 47
The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate.
What might this indicate to the CDI manager?

  • A. CDI staff need education on identifying query opportunities
  • B. The program is successful because documentation has improved
  • C. The loss of a large volume of patients has impacted workflow
  • D. The decrease in hospital census has caused a lack of query opportunities

Answer: A

Explanation:
Explanation
A drastic drop in the physician query rate might indicate to the CDI manager that the CDI staff need education on identifying query opportunities. The physician query rate is a metric that measures the percentage of records that have at least one query sent by the CDI staff to clarify or improve the documentation. A high query rate may reflect a high level of documentation quality issues or a high level of CDI staff vigilance and expertise. A low query rate may reflect a low level of documentation quality issues or a low level of CDI staff awareness and competence 2. Therefore, a drastic drop in the query rate could suggest that the CDI staff are missing some query opportunities or are not following the query policies and procedures. The CDI manager should investigate the reasons for the drop and provide education and feedback to the CDI staff on how to identify and address query opportunities effectively and compliantly 3.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: Understanding CDI Metrics - AHIMA 2 3: The Natural History of CDI Programs: A Metric-Based Model 5


NEW QUESTION # 48
Which of the following is MOST likely to trigger a second-level review?

  • A. A procedure code that increases reimbursement
  • B. An account coded before the discharge summary is available
  • C. A record with multiple major complicating conditions (MCCs)
  • D. A diagnosis that impacts a quality-of-care measure

Answer: C

Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a second-level review is a process that involves a review of coded records by a designated person or team to ensure the accuracy and completeness of coding and documentation1. A second-level review may be triggered by various factors, such as high-risk or high-dollar accounts, coding quality indicators, payer requirements, or internal audit findings1. One of the factors that is most likely to trigger a second-level review is a record with multiple major complicating conditions (MCCs)2. MCCs are diagnoses that significantly affect the severity of illness and resource utilization of a patient, and are assigned a higher relative weight in the DRG system3. A record with multiple MCCs may indicate a complex or unusual case that requires additional validation and verification of the coding and documentation. A record with multiple MCCs may also affect the reimbursement, risk adjustment, and quality scores of the hospital, and therefore may be subject to external scrutiny or audit4. The other options are not as likely to trigger a second-level review, as they are not as indicative of coding or documentation issues or risks. A procedure code that increases reimbursement may not necessarily require a second-level review, unless it is inconsistent with the documentation or the clinical indicators. A diagnosis that impacts a quality-of-care measure may be relevant for CDI purposes, but not necessarily for coding validation.
An account coded before the discharge summary is available may be incomplete or inaccurate, but it may also be corrected or updated before final billing.
CDIP Exam Preparation Guide - AHIMA
Building a Resilient CDI: Second Level Review
Major Complications or Comorbidities (MCC) & Complications or Comorbidities (CC) | CMS Demystifying and communicating case-mix index - ACDIS


NEW QUESTION # 49
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?

  • A. Audit cases that have high SOI/ROM assigned by coders for education and follow-up
  • B. Audit focused cases by physicians that have a higher SOI/ROM for education plan
  • C. Audit cases for missed diagnosis by the CDI practitioner to target in the education plan
  • D. Audit focused APR-DRGs and develop education plan for CDI team and physicians

Answer: D

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


NEW QUESTION # 50
A query should include

  • A. the impact on quality
  • B. information from previous encounters
  • C. the impact of reimbursement
  • D. relevant clinical indicators

Answer: D

Explanation:
Explanation
A query should include relevant clinical indicators from the health record that support the need for clarification and the query options. Clinical indicators are objective and measurable signs, symptoms, laboratory results, diagnostic test results, medications, treatments, and other documented findings that are related to a specific diagnosis or condition. Information from previous encounters, the impact on quality, and the impact of reimbursement are not appropriate to include in a query, as they may introduce bias, lead the provider, or imply a desired response.


NEW QUESTION # 51
Which of the following can be evidence of physician-hospital alignment?

  • A. A low physician agreement rate
  • B. A high clinical documentation integrity practitioner (CDIP) query rate
  • C. A high physician agreement rate
  • D. A high physician response rate

Answer: C

Explanation:
Explanation
A high physician agreement rate can be evidence of physician-hospital alignment because it indicates that the physicians are supportive of the clinical documentation integrity (CDI) program and its goals, and that they are willing to provide accurate and complete documentation in response to CDI queries. A high physician agreement rate also reflects a positive relationship and communication between the CDI team and the physicians, as well as a mutual understanding of the benefits of CDI for patient care, quality reporting, and reimbursement. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2


NEW QUESTION # 52
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