Certified Documentation Integrity Practitioner (CDIP) 1 Practice Exam

These questions are part of the practice quiz. Start practicing

• What is the minimum training requirement for a physician advisor in Clinical Documentation Improvement (CDI)?
• What does the term 'occlusion' refer to in medical coding?
• What indicates effective advocacy within the context of clinical documentation?
• Under what circumstance would a physician query NOT be considered appropriate?
• For document integrity in coding a CVA due to hemorrhage, which information is essential?
• A patient presented with symptoms of gout. What diagnosis was most likely included in their diagnostic statement based on elevated uric acid?
• What would be a valid query regarding pneumonia in a patient undergoing radiation therapy?
• Which document must be included in a patient's record before a surgical procedure is performed, according to Joint Commission Accreditation Standards?
• Which root operation is defined as completing the closure of a tubular body part or orifice?
• What is the denial rate for DRG 682 if there are 10 total denials?
• Who should assist in establishing the retention of queries at a healthcare facility?
• What is a primary focus of Recovery Audit Contractors (RAC) in healthcare?
• What kind of clinical evidence supports querying a physician for better documentation?
• What could result from using a code that inaccurately reflects the service provided?
• Which symbol of punctuation is used in the Tabular List to enclose synonyms, alternative wording, or explanatory phrases?
• Which of the following best describes the Comprehensive Error Rate Testing (CERT) process?
• Which organization has CMS engaged to assist in record reviews of certain DRGs and documentation concerns?
• Patients with multiple procedures during a hospital stay are assigned to what?
• For assessing status asthmaticus, which phrase should coders look for in the patient's documentation?
• What manifests as hematemesis, indicating acute upper gastrointestinal bleeding?
• When coding a cancer diagnosis that has been previously treated, which code reflects a history of malignancy?
• What is the first significant challenge in establishing a CDI program?
• What document outlines ethical decision-making processes for CDI professionals?
• When must a physician's order be issued for performing a surgery?
• In the context of a query, which term describes a query that improperly directs a provider to document a specific response?
• What is the process being developed to integrate the CDI model with the EHR called?
• Which term is utilized in coding to denote a condition that is uncertain at the time of assessment?
• What is the primary responsibility of a medical coder?
• What approach code is designated for open procedures?
• Which term describes the procedure performed for the definitive treatment rather than diagnosis?
• What condition is classified as significant when coding for a patient with CHF and exacerbation of symptoms?
• In determining the working DRG, what is the primary focus of the CDS review?
• According to coding guidelines, which conditions would be classified as secondary diagnoses in a patient with CHF and COPD?
• When should clinical documentation specialists formulate a query?
• What defines targeted accounts for mechanical ventilation based on length of stay?
• What is the correct code for an open fusion of the right ankle with internal fixation?
• Which of the following is true regarding unbundling?
• What type of answer format includes options for free responses, specific selections, or binary confirmations?
• The criteria for mechanical ventilation relates to which aspect of length of stay?
• Which document should new CDS members read and sign to understand ethical standards in CDI?
• In a situation where a patient received a transfusion for an acute GI bleed, and the query asks, "Is this blood loss anemia?" this query is:
• What should be the main focus when documenting a patient's health record?
• What role does the attending physician play regarding the discharge summary?
• Which of the following is a reason for a query to be created during documentation review?
• During a CDI review, which scenario best indicates an appropriate query?
• What should be analyzed in a medical record to confirm a diagnosis of CKD stage V?
• If a pressure ulcer is noted on admission and later progresses, what should the POA assignment be?
• What are the local and national policies published by Medicare called that define specific ICD codes that support medical necessity?
• A patient suffered a tibia fracture from a minor fall. How is this fracture coded if the patient is known to have osteoporosis?
• Which agency is mandated by CMS to address improper Medicare payments?
• What term describes complete immobility due to severe physical disability without a neurologic cause?
• Which modifiers were introduced to provide greater specificity in lieu of modifier 59?
• Which committee should Anywhere Hospital utilize to assist with problems interacting with medical staff?
• Which set of core measures is identified by the Joint Commission and CMS?
• Who should provide support during the CDI program according to best practices?
• Which is an example of a core measure NOT currently identified?
• What terminology is preferred in the CPT codes for treatment of fractures?
• Which information is generally included in a query to a physician?
• What is the primary role of hospitalists in a CDI training context?
• Which of the following indicates a lack of clarity in documentation regarding a patient's condition?
• Which question is crucial for accurate reporting of hospital-acquired conditions?
• Who should be part of the CDI oversight committee to help build physician support for the program?
• What is the appropriate action regarding queries initiated during a patient’s stay upon discharge?
• What term describes the interactive process of sharing experiences about clinical documentation in training?
• Which governmental audit agency calculates the national paid claims error rate for Medicare fee-for-service claims?
• Which surgical procedure is considered highest in the surgical hierarchy for ear, nose, mouth and throat?
• What is the primary reason Dr. Bach decided to stop negotiating problems between coders and physicians?
• When documenting mechanical ventilation, which time aspect is important to consider?
• The rule that helps determine if inpatient admissions are payable under Medicare Part A is known as?
• The process of evaluating the use of healthcare services and facilities is known as?
• In terms of CDI competencies, which is highly valued for ensuring effective communication?
• Which component is essential for the success and sustainability of a CDI program?
• What should be included in the documentation for a patient who suffered a cardiac arrest immediately following admission?
• In a compliant CDI program, who is ultimately responsible for documentation?
• What should you not code for during an outpatient visit if documented as "rule out"?
• What is the primary purpose of a query in documentation integrity?
• Which code would you use for chronic systolic (congestive) heart failure?
• Which type of services are billed the same as outpatient services?
• Which code is assigned for congestive heart failure due to hypertension?
• What are some causes of nonpressure ulcers of the lower limb?
• If a provider determines that an amendment of the electronic health record is needed, what must the provider ensure?
• If a patient is prescribed Haldol, what condition might a coder suspect?
• What is the best course of action for a clinical documentation specialist when discrepancies exist regarding a patient's admission condition?
• Which of the following components does the Glasgow Coma Scale evaluate?
• What role does the attending physician serve in clinical documentation?
• What is indicated by the ICD-10 code I50.9?
• What is the significance of crystalline uric acid in diagnosing joint conditions?
• A review of patient records for evaluation of medical necessity falls under which category?
• What is the appropriate code for "hypertensive heart disease with heart failure"?
• What type of shock is most commonly seen in postoperative patients following large fluid losses?
• How can a query enhance the accuracy of health record documentation?
• Which group of physicians typically receive priority for CDI training?
• Which component is essential for a CDI program?
• Which of these scenarios does not warrant a query related to the discharge diagnosis?
• Which of the following is NOT typically included in the responsibilities of a compliance officer in a CDI program?
• What type of complication would be documented as present only after admission?
• In a case where acute CHF is documented but the query suggests "please document acute CHF," this query is considered:
• If a CDS specialist faces issues with physician responses to clinical queries, what should they do?
• What should a coding supervisor do if there is insufficient information to compare error rates among coders?
• Which background is preferred for a candidate applying for a CDI position at a large healthcare facility?
• What should a coder do if they are uncertain about the validity of a diagnosis noted in the medical record?
• What additional codes are required when documenting severe sepsis?
• What should a CDS do when faced with ambiguous or incomplete health record documentation?
• For two lacerations of the arm repaired with simple closures, how should the coder proceed?
• What is the principal role of the clinical documentation specialist in a healthcare facility?
• During a clinic visit, what should be reported for a patient whose note states "rule out CHF" and exhibits shortness of breath and pedal edema?
• Which type of query would prompt a provider to document clinical indicators that are already evident in the medical record?
• How are coding rules associated with fraud and abuse in the context of HIM professionals?
• What is a common format for queries used in a CDI program?
• What should a query policy include regarding the physician's role?
• What is a key role of the physician advisor in CDI?
• What is the admission criterion related to a patient presenting with vaginal bleeding?
• When should physician queries be initiated during the admission process?
• Which of the following is a form of severe protein malnutrition affecting children during periods of famine?
• In the event that individual payer policies conflict with coding rules, what is the recommended action?
• What condition must be reported when determining hospital-acquired conditions?
• Why is it important to understand why a facility wants to improve clinical documentation?
• Which of the following best describes effective communication?
• What is a key concept to consider in the communication of a CDI program?
• What is the correct ICD-10-PCS code for laparoscopic repair of a right diaphragmatic hernia?
• When a patient is admitted for treatment of a secondary malignancy with an active primary site, what should be designated as the principal diagnosis?
• Which procedure requires inpatient approval for admission based on the admission criteria provided?
• What does the CDS perform case review after admission to obtain?
• What is required for a facility to bill inpatient services if observation status has been ordered?
• When adding additional information to an electronic health record, what is a crucial element to include?
• Who should be included in the oversight of the CDI program?
• What combination of codes would be assigned for acute on chronic systolic heart failure?
• Which surgical procedure is considered lowest in the surgical hierarchy for ear, nose, mouth and throat?
• A compliant CDI program should include which of the following components?
• What role does the CDI manager play in relation to new CDS members?
• What is the likely POA indicator if a patient has a postoperative complication that was not present upon admission?
• Which ICD-10 code would be appropriate for a patient who is noncompliant with their antihypertensive medication?
• Which of the following is not a suggested key competency for a CDI professional?
• The practice of using a code that results in higher payment than the actual service provided is known as what?
• Which tool is essential for tracking the work of the CDI professional?
• Which best describes an appropriate action for a clinical documentation specialist before coding?
• What is the primary role of coding professionals in the context of billing abstracts?
• What must the coding staff understand to effectively support the CDI program?
• Which quality measure is directly affected by implementing a CDI program?
• What coding is required for severe sepsis with acute organ dysfunction?
• Which types of pacemaker devices require a unique ICD-10-PCS code?
• How does physician leadership contribute to a CDI program?
• Who is ultimately responsible for the documentation of a patient in the hospital?
• In ICD-10-PCS, what value is used for a character that does not apply?
• What document outlines audit and review areas pursued by the Department of Health and Human Services?
• What type of note is used for a patient's history when readmitted within 30 days?
• What factor could impact code assignment for the embolism code in a patient with a CVA and hemorrhage determined to be caused by an embolism?
• Which factor is NOT necessary when assigning a code for CVA?
• How frequently should queries in a CDI program be audited for format and appropriateness?
• What is the goal of an Electronic Query Process?
• Which person plays a critical role in ensuring effectiveness in a CDI program by participating in oversight committees?
• When is a query for sepsis considered warranted?
• What terms should the coder look for to substantiate status asthmaticus?
• A facility with a MSDRG utilization rate of 85% of MCCs may indicate which concern?
• What is a possible outcome of poorly documented primary and secondary neoplasms?
• Which qualified Non-Physician Provider (NPP) is NOT included in E/M services?
• A patient with a history of Alzheimer's is showing signs of possible medication underdosing. What behavior supports this assumption?
• EHR systems that primarily use point and click navigation create what kind of risk?
• When coding for hospital-acquired conditions, what is key to ensuring payment accuracy?
• Who bears responsibility for the content, quality, and signing of a discharge summary?
• What element must be considered when determining an ICD-10 code for a condition involving a CVA and a secondary complication?
• A patient with a history of liver transplant presents with jaundice and Stage IV CKD. What action should be taken concerning the transplant?
• How should newly diagnosed adenocarcinoma of the fallopian tube be coded?
• A cerebral palsy patient was diagnosed with acute bronchitis and possible pneumonia. What additional information will impact their ICD-10 code assignment?
• If a service is deemed reasonable and necessary for a diagnosis or treatment, how is it classified?
• What type of pneumonia should be queried when documentation is unclear about a patient with difficulty swallowing?
• Why is it important to analyze the potential impact of a CDI program?
• After a cholecystectomy, what should be coded as the principal diagnosis when the patient develops intractable nausea and vomiting?
• What triggers the generation of a query in health record documentation?
• For the diagnosis of permanent atrial fibrillation, which ICD-10 code is appropriate?
• Which documentation practice supports the clarity and accuracy of health records?
• In coding for a recent fall leading to an evaluation, how should the patient's previous surgery for adenocarcinoma of the uterus be handled?
• What should be the approach of the HIM department towards a billing abstract narrative that is too lengthy and inconsistent with facility reporting?
• What serious ethical issue is associated with coding practices?
• How should a biopsy performed immediately before a definitive surgery be coded in ICD-10-PCS?
• What is the preferred method of documenting when a patient has not been taking prescribed medications effectively?
• Which term can be used synonymously with "query" in clinical documentation?
• What is another term for outcome measures reports utilized by leaders?
• What is the appropriate root operation code for visual exploration of the abdominal cavity?
• In the event of unclear documentation regarding a patient's condition, how should a clinical documentation specialist proceed?
• In a case where a patient is discharged with a UTI diagnosis, what should the CDS consider querying?
• After surgery, if complications arise, what is the first step according to coding guidelines?
• What is the principal diagnosis in the case of a patient admitted with elevated white blood cells and pneumonia symptoms?
• What is the financial impact for DRG 682 when the total payments adjusted is $6818.40?
• Which of the following best describes the intention behind concurrent documentation review in a CDI program?
• In ICD-10, how is a fracture resulting from a fall in a patient with known osteoporosis classified?
• What document ensures that all program staff have signed off on CDI policies and procedures?
• What should Dr. Smith, the physician advisor, avoid doing in relation to documentation?
• When the documentation in the medical record is insufficient to assign a more specific code, which type of code is assigned?
• To avoid patient safety issues related to abbreviations, what is a recommended practice?
• What is a key question for a new or restructuring CDI program to ask?
• What is the term for the process organizations use to track and address denials?
• What is the denial rate for DRG 637 if there are 5 total denials out of 20?