Certified Documentation Integrity Practitioner CDIP Exam Online Dumps

1. A query should be generated when documentation contains a

2. 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?

3. The correct coding for heart failure with preserved ejection fraction is

4. When a change in departmental workflow is necessary, the first step is to

5. When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to

incomplete records for failure to respond to queries?

6. 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)?

7. A modifier may be used in CPT and/or HCPCS codes to indicate

8. Hospital policy states that physician responses to queries should be no longer than timely payer filing requirements. A physician responds to a query after the final bill has been submitted.

How should administration respond in this situation?

9. 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?

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

11. 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?

12. The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to

13. Which of the following is an example of a hospital-acquired condition when not present on admission?

A. Iatrogenic pneumothorax with lung biopsy

B. Iatrogenic pneumothorax with venous catheterization

C. Pressure ulcer stage II

D. Pressure ulcer stage III

14. Current smoker

What is the correct diagnostic related group assignment?

15. 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?

16. A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side.

The default code is

17. 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?

18. A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate

19. 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?

20. A clinical documentation integrity practitioner (CDIP) is looking for clarity on whether a diagnosis has been "ruled in" or "ruled out".

Which type of query is the best option?

21. 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?

22. When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?

23. Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?

24. Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?

25. 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?

26. A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

27. Besides the physician advisor/champion, who should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives?

28. Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program?

29. Review the following query to determine if it is compliant:

Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?

Dehydration

Hyponatremia

Hypernatremia

Chronic kidney disease (indicate stage)

Other (please specify)

30. The correct coding for insertion of a dialysis catheter into the right internal jugular vein with the tip ending in the cavoatrial junction is

31. Which member of the clinical documentation integrity (CDI) team can help provide peer-to-peer level of education on the importance of accurate documentation and query responses?

32. AHIMA suggests which of the following for an organization to consider as physician response rate and agreement rate?

33. Which of the following falls under the False Claims Act?

34. A clinical documentation integrity practitioner (CDIP) is developing a plan to promote the CDI program throughout a major hospital. It is proving challenging to find support.

What is a primary step for the CDIP?

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

36. A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note.

Which further clarification should be done regarding present on admission (POA) indicator of fall?

37. An 86-year-old female is brought to the emergency department by her daughter. The patient complains of feeling tired, weak and excessive sleeping. The patient's daughter comments that patient's mental condition has not been the same. Lab results are unremarkable except for a sodium level of 119, a BUN of 22, and a creatinine of 1.35. The patient receives normal saline IV infusing at 100 cc/hr. The admitting diagnosis is weakness, altered mental status and dehydration.

Which of the following queries is presented in an ethical manner thus avoiding potential fraud and/or compliance issues?

38. 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?

39. 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.

40. Several physicians at a local hospital are having difficulty providing adequate documentation on patients admitted with a diagnosis of pneumonia with or without clinical indications of gram-negative pneumonia. Subsequently, clinical documentation integrity practitioners (CDIPs) are altering health records.

Which policy and procedure should be developed to ensure compliant practice?

41. 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?