CDIP Exam Questions and Answers (Graded A)

eMAR - Answer- Electronic medication administration record PACS - Answer- Picture archive and communication system CPOE - Answer- Computerized provider/practitioner/physician order entry CAMP - Answer- Coaching, asking, mastering, peer learning ICEHR - Answer- Integrated care EHR HCO - Answer- Health care organization HIM - Answer- Health Information Management Stage 0 EHR implementation - Answer- Lowest level of transformation Stage 1 EHR implementation - Answer- Electronic capture of health info is in standardized format, track key clinical conditions, communicate info for care coordination process, reports clinical quality measure and public health info, uses info to engage px and their families in their care Stage 2 EHR implementation - Answer- Increases amount of patient-centric measures providers require Stage 3 EHR implementation - Answer- •Vital signs and flow sheets required as electronic documentation. • Median stage most acute care facilities have reached Stage 4 EHR implementation - Answer- Strongest correlation btw higher quality indicators and hospital's EHR scores. Hospital has a CPOE system in place along with 2nd level of clinical decision support capabilities related to EBM protocols Stage 5 EHR implementation - Answer- HCO fully implements closed loop eMAR environment in at least one patient care area Stage 6 EHR implementation - Answer- Implementing full physician documentation and charting using structured templates for at least one px areas Stage 7 EHR implementation - Answer- • SEHR benchmark with a mixture of discreet data, document imaging and medical imaging. • Makes health info available to patients 5 Rights to medication - Answer- Right patient, medication, dose, route, time NLP - Answer- Natural language processing 4 phases of NPL - Answer- • : Machine Translation • : Artificial intelligence • 1970-g1989: Grammatico-logical phase • : Statistical language processing Real-time deficiency tracking - Answer- Provides mined information from a narrative content combined with structured EHR data to identify deficiencies in clinical documentation SNOMED-CT - Answer- Systemized Nomenclature of Medicine-Clinical Terms CAC - Answer- Computer Assisted Coding CLU - Answer- Clinical Language Understanding ICD-10-CM/PCS - Answer- International Classification of Disease, Tenth Revision, Clinical Modification and Procedure Coding System RVU - Answer- Relative value unit CPT - Answer- Current Procedural Terminology Six levels of higher level complex thinking - Answer- KCAASE: Knowledge, Comprehension, Application, Analysis, Synthesis, Evaluation. MLP - Answer- Mid level practitioner CIM - Answer- Complimentary and Integrative Medicine IPPS/OPPS - Answer- Inpatient prospective payment system/ Outpatient prospective payment system ADT - Answer- Admission Discharge Transfer CMS - Answer- Centers for Medicare and Medicaid Services NCHS - Answer- National Center for Health Statistics HHS - Answer- Health and Human Services AHA - Answer- American Hospital Association Parties that developed and approved ICD-9-CM - Answer- AHA, AHIMA, CMS, NCHS Timeliness - Answer- Is the biggest challenge for discharge summary followed by consistency. DRG- 1975 - Answer- Diagnosis related group developed by Robert Fetter in 1975 ICD-9 codes into DRG- 1982 - Answer- CMS started paying for Medicare using a method that groups ICD-9 codes into DRGs More refined DRG-2008 i.e. MS-DRG (Medicare Severity) - Answer- CMS has used this since 2008. Relies to a greater degree on a patients SOI rather than just resource utilization to calculate reimbursement. 3 severity based DRG systems - Answer- Medicare severity DRG (MS-DRG), All patient DRGs (AP-DRGs), All Patient Refined DRGs (APR-DRGs) AP-DRG 1987 - Answer- 3M company created AP-DRG in 1987 as part of NY non-Medicare hospital reimbursement program AP-DRG 1990 - Answer- 3M company created APR-DRG in 1990. Many states use this for Medicaid reimbursement. Also used for quality indicators MS-DRG and AP-DRG - Answer- 1. Stand alone DRGs (TIA), 2. Without CC 3. With CC 4. With Major CC APR-DRG - Answer- 1. No stand alone DRGs 2. Severity 1 (minor) 3. Severity 2 (moderate) 4. Severity 3 (major) 5. Severity 4 (extreme). APR-DRGs are assigned based on SOI and ROM levels (subclasses) APR-DRG - Answer- There is a level score between 1 and 4 for SOI and 1 for ROM MDC - Answer- Major Diagnostic Category Hospitals focus on inpatient clinical documentation (CD) because of - Answer- Large reimbursement, coding quality and medical necessity for inpatient services Reasons for Outpatient CD - Answer- Increasing outpx volume, diagnostics, outpx surgery, observation bed admission HCPCS - Answer- Healthcare Common Procedure Coding System AAPC - Answer- American Academy of Professional Coders Coding - Answer- Translating physician clinical documentation into diagnostic and procedural coded data- aggregates diagnostics, treatment and response info of px into uniform data set. Helps with research, planning, billing and patient-care purposes. Progress note - Answer- The essence of the health record on which the coder relies Anesthesiologist - Answer- A query is necessary if there's a conflict between them and the attending physician. AHD - Answer- American Hospital Directory OIG - Answer- Office of the Inspector General QIO - Answer- Quality Improvement Organization ASCQR - Answer- Ambulatory Surgical Center Quality Reporting Recommended Data to review - Answer- Discharges by service and by MDC, Discharges by DRG, CMI, Complications and Major Complication Rates, Severity Levels(MS-DRG and APR-DRG), Medicare Quality Indicators FMQAI - Answer- Florida Medical Quality Assurance Inc. contracted with CMS to develop the Medication Measures Special Innovation Project NQF - Answer- National Quality Forum IQR - Answer- Inpatient Quality Reporting PQRS - Answer- Physician Quality Reporting System CC/MCC focus - Answer- ARF, Acute respiratory failure, congestive heart failure, encephalopathy, excision debridement, HIV, AIDS, TB, sepsis, anemia, MI MEDPAR - Answer- Medicare Provider and Analysis Review APC - Answer- Ambulatory Payment Classification. It allows for multiple assignments for each encounter and for the analysis of clinical documentation to remain on coding level Capture rate - Answer- Key indicator used to monitor a successful CDI program. Ten best CDI Operational Practices - Answer- 1. CDI is Px centered 2. Create a Vision 3. Initial compulsory physician education 4. Creating policies and procedures that require sign-off 5. Maintaining complete query documentation 6. Feedback loop between denials, management, and CDI 7. Feedback loop between CDI and compliance 8. Feedback loop between HIM and CDI 9. Continuous targeted physician education and relationship building 10. Using rigorous management tools. Organizations responsible for functions that continually integrate with CDI - Answer- Compliance, HIM, case manager, finance, medical staff, data analysts, case mix managers, EHR staff Key outcomes of CDI - Answer- High-quality care, high-perceived quality, improved px satisfaction and accurate reimbursement CDI best practices feedback loop with - Answer- Denials, Management, Compliance, HIM, CDI program staff RAC - Answer- Recovery Audit Contractors MAC - Answer- Medicare Administrative Contractors Best practices for CDI must benefit the system in at least 2 of the following - Answer- Operation, strategy and compliance 4 criteria for describing basics of best of practice CDI program - Answer- • Remain constant over time (timeless) • Practice supported by research and actual application by multiple healthcare systems • Affect at least 2 management areas (operation, strategy and compliance) • Provide some measurable value to the organization HIM - Answer- CDI staff work directly with HIM staff to obtain data about retrospective physician query 5 Best practices for management of financial measures in the CDI program - Answer- 1. Track CMI closely and identify real patient mix change 2. Track and report on CC rates overall and by service 3. Know the benchmarks and validate the data regularly 4. Do the right thing for the most accurate data outcome 5. Create a concurrent process with physician leadership. HIPAA - Answer- Health Information Portability and Accountability Act CMS and OIG - Answer- The two-part theory for high-quality clinical documentation is a cause and effect theory is derived from CMS and OIG Activities clinical documentation impacts - Answer- Care, quality indicators, reimbursement, healthcare planning and research EBM standards - Answer- Design, Terminology, Performance, Procedural JCAHO - Answer- Joint Commission on Accreditation of Healthcare Organization Estimated payment - Answer- Volume x Weight x Hospital-Specific Base Rate 4 levels to consider in order to staff the program - Answer- Reporting Management Staffing Physician leadership CDIP - Answer- Should be an effective physician communicator and excellent at reading clinical documentation and data to uncover low-quality clinical documentation. UHDDS - Answer- Uniform Hospital Discharge Data Set Highest level of quality in clinical documentation is gotten from - Answer- Health record review process and physician queries HPMP - Answer- Hospital Payment Monitoring Program Septicemia - Answer- Systemic disease with the presence of persistent pathogenic micro-organisms or toxins in the blood SIRS- Systemic inflammatory response syndrome - Answer- Systemic response to infection or trauma Sepsis - Answer- SIRS caused by infection Severe sepsis - Answer- Sepsis + organ failure/dysfunction Septic Shock - Answer- Sepsis + CVS failure or hypotension. Endotoxic shock and gram negative shock are synonymous with septic shock. Septic shock= severe sepsis Bacteremia - Answer- Bacteria in blood without any inflammatory response Urosepsis - Answer- Infection confined to the urinary system- puris, bacteriuria Problematic CMS diagnosis - Answer- • Malnutrition • Respiratory failure • Sepsis • Renal failure • Acute blood loss anemia • Congestive heart failure • Pneumonia CMI - Answer- Average DRG relative weight for inpatient cases and an indicator of average reimbursement per patient KPI - Answer- Key Performance Indicators Clinical documentation - Answer- Is the basis of the coding and billing activity in every organization DTM - Answer- Direct Teaching Method Key components of compliant CDI program - Answer- 1. Documented mandatory physician training 2. Detailed query documentation 3. CDI policies and procedures with annual sign-off from all program staffing Goal of CDI compliance review - Answer- Is to monitor compliant query generation and physician responses HIMSS - Answer- Healthcare Information and Systems Society DORA - Answer- Department of Regulatory Agencies