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AHIMA Certified Documentation Integrity Practitioner Sample Questions (Q35-Q40):

NEW QUESTION # 35
A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

A. The associated diagnosis and the clinical rationale in the progress notes
B. A cause-and-effect relationship between anemia and the underlying cause
C. The associated diagnosis directly on the query form
D. That the blood loss was not clinically significant

Answer: A

Explanation:
Explanation
The physician needs to document the associated diagnosis and the clinical rationale in the progress notes for the CDIP to record the query as answered and agreed because this is the best way to ensure that the health record reflects the patient's condition and treatment accurately and completely. The associated diagnosis is the condition that caused or contributed to the blood loss and the need for transfusion, such as acute blood loss anemia, hemorrhage, or trauma. The clinical rationale is the explanation of how the diagnosis is supported by the clinical indicators, such as laboratory values, vital signs, symptoms, or procedures. Documenting the associated diagnosis and the clinical rationale in the progress notes also helps to avoid any confusion or inconsistency with other parts of the health record, such as the discharge summary or the coding. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Guidelines for Achieving a Compliant Query Practice (2019 Update)3

NEW QUESTION # 36
Automated registration entries that generate erroneous patient identification-possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit-is an example of a potential breach of:

A. Patient identification and demographic accuracy
B. Documentation integrity
C. Authorship integrity
D. Auditing integrity

Answer: A

Explanation:
Explanation
Patient identification and demographic accuracy is the process of ensuring that the patient's identity and personal information are correctly recorded and verified in the health record and other systems. A potential breach of this process could result in automated registration entries that generate erroneous patient identification, which could lead to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit2 Authorship integrity is the process of ensuring that the source and content of the health record are authentic, accurate, complete, and consistent. Documentation integrity is the process of ensuring that the health record reflects the patient's clinical status, treatment, and outcomes. Auditing integrity is the process of ensuring that the health record is reviewed and monitored for compliance, quality, and improvement purposes2
1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 2:
https://my.ahima.org/store/product?id=67077

NEW QUESTION # 37
When writing a compliant query, best practice is to

A. include all relevant clinical indicators
B. use the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present
C. direct the physician to a specific diagnosis
D. use a yes/no query format for specificity of a diagnosis

Answer: A

Explanation:
Explanation
One of the best practices for writing a compliant query is to include all 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. Including clinical indicators helps to provide the rationale for the query, avoid leading or suggesting a desired response, and ensure that the query is based on evidence and not assumptions. The other options are not best practices for writing a compliant query.
Directing the physician to a specific diagnosis is leading and noncompliant. Using the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present is vague and imprecise. Using a yes/no query format for specificity of a diagnosis is discouraged, as it limits the provider's choices and may not capture the true clinical picture.

NEW QUESTION # 38
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?

A. No query is needed
B. Query physician for POA
C. Take the case to physician advisor/champion to discuss further action
D. Bring this case up in weekly Health Information Management meetings for further action

Answer: B

Explanation:
Explanation
A query should be generated to ask the physician for the POA indicator of the fall because the documentation is unclear whether the fall was present at the time of inpatient admission or not. The POA indicator is used to identify conditions that are present or not present at the time of admission, and has payment implications for certain hospital-acquired conditions (HACs). According to CMS, a fall resulting in trauma is one of the HACs that will not be paid at a higher rate if it is not present on admission. Therefore, it is important to clarify the POA indicator of the fall to ensure accurate coding and reimbursement. A query should be non-leading, concise, clear, relevant, and consistent with CDI standards and guidelines.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) Coding | CMS1 Present on Admission Indicators - Novitas Solutions2

NEW QUESTION # 39
Which of the following clinical documentation integrity (CDI) dashboard metrics is frequently used to help evaluate the credibility of CDI practitioner queries and the success of the CDI program?

A. CDI query rate
B. CDI agreement rate
C. Provider response rate
D. Provider agreement rate

Answer: D

Explanation:
Explanation
The provider agreement rate is the percentage of queries that result in a change in the documentation or coding that is consistent with the query. It is a measure of the accuracy and appropriateness of the queries, as well as the provider's acceptance of the CDI program's recommendations. A high provider agreement rate indicates that the CDI practitioners are asking relevant and compliant queries that improve the quality and specificity of the documentation. The other options are not directly related to the credibility of the queries or the success of the CDI program. The CDI agreement rate is the percentage of queries that agree with the coder's final DRG assignment. The CDI query rate is the percentage of records that generate a query from the CDI practitioner.
The provider response rate is the percentage of queries that receive a response from the provider.

NEW QUESTION # 40
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CDIP Most Reliable Questions | CDIP Vce Download

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AHIMA Certified Documentation Integrity Practitioner Sample Questions (Q35-Q40):

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