CDIP EXAMS SET FULL SOLUTION
QUESTIONS AND CORRECT ANSWERS
●● When should a provider provide documentation for the best quality
of documentation?
Answer: Right after caring for a patient
●● What type of health record documentation should be top priority
when undertaking a CDI program?
Answer: Inpatient Acute Care Health Record Documentation
●● What are the key activities of a CDI program? (2)
Answer: Concurrent review and concurrent physician inquiry
●● What is a common function that has created a problem for data
integrity of the health record that healthcare organizations should
establish compliance guidance and well thought-out processes on?
Answer: Copy and Paste
●● When should a medical history and physical examination be
completed?
Answer: - No more than 30 days before or 24 hours after admission or
registration
,- Prior to surgery or procedure requiring anesthesia services
●● In what timeframe should a final diagnosis of a health record and a
discharge summary be placed according to CMS conditions of
participation?
Answer: Within 30 days following discharge
●● Who does OIG used to administer Medicare A and B as well as to
process claims for services rendered?
Answer: Medicare Administrative Contractors (MACs)
●● What is important about ventilation in the medical record?
Answer: The timeframe of ventilation.
●● What is a common type of malnutrition that the OIG has identified as
an over-used diagnosis resulting in overpayment under the MS-DRG
system?
Answer: Kwashiorkor Malnutrition
●● Four standards used in EBM (Evidence Based Medicine)
Answer: Design
Terminology
Performance
,Procedural
●● 7 Quality Clinical Documentation Criteria
Answer: Legible
Reliable
Precise
Complete
Consistent
Clear
Timely
Make sure to be able to identify examples of these*
●● Each clinical criteria in a patient's health record must meet what?
Answer: ALL seven of the criteria (gold standard) for clinical
documentation
●● What might be required if a discharge summary is inconsistent with
other entries in the health record?
Answer: A query
●● What does the 2014 ICD-10-PCS guidelines state is essential to
achieve complete and accurate documentation?
, Answer: A joint effort between the healthcare provider and the coder
●● When there is provider disagreement on a diagnosis in the record or
the diagnosis is unclear coders must always?
Answer: Submit a query to clarify
●● Which physicians documentation is used for coding if two providers
cannot agree?
Answer: The attending physician's documentation
●● What all is required in an Emergency Department Record?
Answer: The ED record must include the time, means of arrival,
immediate care and treatment notes, final disposition, condition at
discharge, and instructions for follow-up.
●● Often the physician copies the entire__________and pastes it into
the discharge summary, giving the appearance that all the diagnoses on
the list are pertinent to the current admission.
Answer: Problem List
●● The purpose and scope of the problem list in all healthcare settings
(inpatient, outpatient facility, and physician practice) should:
Answer: - Facilitate continuity of care between patient visits
QUESTIONS AND CORRECT ANSWERS
●● When should a provider provide documentation for the best quality
of documentation?
Answer: Right after caring for a patient
●● What type of health record documentation should be top priority
when undertaking a CDI program?
Answer: Inpatient Acute Care Health Record Documentation
●● What are the key activities of a CDI program? (2)
Answer: Concurrent review and concurrent physician inquiry
●● What is a common function that has created a problem for data
integrity of the health record that healthcare organizations should
establish compliance guidance and well thought-out processes on?
Answer: Copy and Paste
●● When should a medical history and physical examination be
completed?
Answer: - No more than 30 days before or 24 hours after admission or
registration
,- Prior to surgery or procedure requiring anesthesia services
●● In what timeframe should a final diagnosis of a health record and a
discharge summary be placed according to CMS conditions of
participation?
Answer: Within 30 days following discharge
●● Who does OIG used to administer Medicare A and B as well as to
process claims for services rendered?
Answer: Medicare Administrative Contractors (MACs)
●● What is important about ventilation in the medical record?
Answer: The timeframe of ventilation.
●● What is a common type of malnutrition that the OIG has identified as
an over-used diagnosis resulting in overpayment under the MS-DRG
system?
Answer: Kwashiorkor Malnutrition
●● Four standards used in EBM (Evidence Based Medicine)
Answer: Design
Terminology
Performance
,Procedural
●● 7 Quality Clinical Documentation Criteria
Answer: Legible
Reliable
Precise
Complete
Consistent
Clear
Timely
Make sure to be able to identify examples of these*
●● Each clinical criteria in a patient's health record must meet what?
Answer: ALL seven of the criteria (gold standard) for clinical
documentation
●● What might be required if a discharge summary is inconsistent with
other entries in the health record?
Answer: A query
●● What does the 2014 ICD-10-PCS guidelines state is essential to
achieve complete and accurate documentation?
, Answer: A joint effort between the healthcare provider and the coder
●● When there is provider disagreement on a diagnosis in the record or
the diagnosis is unclear coders must always?
Answer: Submit a query to clarify
●● Which physicians documentation is used for coding if two providers
cannot agree?
Answer: The attending physician's documentation
●● What all is required in an Emergency Department Record?
Answer: The ED record must include the time, means of arrival,
immediate care and treatment notes, final disposition, condition at
discharge, and instructions for follow-up.
●● Often the physician copies the entire__________and pastes it into
the discharge summary, giving the appearance that all the diagnoses on
the list are pertinent to the current admission.
Answer: Problem List
●● The purpose and scope of the problem list in all healthcare settings
(inpatient, outpatient facility, and physician practice) should:
Answer: - Facilitate continuity of care between patient visits
