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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Compliance | 4–8% | - Fraud and abuse prevention - AHIMA standards and regulatory requirements - Compliance monitoring and reporting - Legal and ethical documentation practices |
| Topic 2: Record Review & Document Clarification | 24–28% | - Query tracking and follow-up - Compliance with query standards - Ethical provider query development - Identify documentation gaps and specificity issues - POA, HAC, SOI, ROM clarification |
| Topic 3: Clinical Coding Practice | 22–26% | - Payer requirements and reimbursement models - DRG, CPT, and HCPCS code assignment - Principal and secondary diagnosis identification - ICD-10-CM/PCS coding conventions and guidelines - Coding software and reference resources |
| Topic 4: Leadership | 17–22% | - Policy and procedure creation - CDI program development and promotion - Provider engagement and communication - Interdisciplinary collaboration |
| Topic 5: CDI Metrics & Statistics | 14–18% | - Quality audits and compliance monitoring - Benchmarking and reporting - DRG comparison and denial analysis - Query response and volume tracking |
| Topic 6: Research & Education | 11–15% | - Provider and staff education - Best practice research and implementation - Regulatory and guideline updates - Documentation improvement training materials |
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?
Correct Answer: D 🗳️
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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?
Correct Answer: B 🗳️
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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?
Correct Answer: C 🗳️
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A 56-year-old male patient complains of feeling fatigued, has nausea & vomiting, swelling in both legs.
Patient has history of chronic kidney disease (CKD) stage III,
coronary artery disease (CAD) & hypertension (HTN). He is on Lisinopril. Vital signs: BP 160/80, P 84, R 20, T 100.OF. Labs: WBC 11.5 with 76% segs, GFR 45. CXR showed slight left lower lobe haziness. Patient was admitted for acute kidney injury (AKI) with acute tubular necrosis (ATN). He was scheduled for hemodialysis the next day. Two days after admission patient started coughing, fever of 101.8F, CXR showed left lower lobe infiltrate, possible pneumonia. Attending physician documented that patient has pneumonia and ordered Rocephin IV. How should the clinical documentation integrity practitioner (CDIP) interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC)?
Correct Answer: C 🗳️
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Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?
Correct Answer: B 🗳️
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