CDIP Domain 2: Leadership Exam

AHIMA - Answer- American Health Information Management Association ACDIS - Answer- Association of Clinical Documentation Improvement Specialists IDT - Answer- Interdisciplinary Team LOS - Answer- Length of Stay The RHIT, RHIA or CCS should have how many years of inpatient coding experience before becoming a CDI specialist? - Answer- at least 3-5 years Hospitalists - Answer- Physicians whose primary professional focus is the general medical care of hospitalized patients Timeframes for completion of queries should be included in - Answer- the programs policies Physician Champions - Answer- Providers who are very engaged with the CDI program and understand and believe in the value of participating in a program that promotes specificity and consistency in documentation in the medical record Physician Advisor - Answer- Valuable resource who can help answer any clinical questions for the CDI specialist before writing a query, and will help ensure that the queries a brand new CDI specialist writes are as clinically accurate as possible. Query response expectations are up to the discretion of - Answer- the facility Retrospective Queries - Answer- Queries that are written post-discharge CDI Toolkit - Answer- provides information for establishing a CDI program Policies and procedures should be in what type of format for easy reference? - Answer- Written MS-DRG - Answer- Medicare Severity-Diagnosis Related Groups SOI - Answer- Severity of Illness ROM - Answer- Risk of Mortality A multi-disciplinary team approach should include - Answer- physicians and their mid-levels (ARNPs and PAs), clinical documentation specialists, coders, administration, and appropriate hospital staff RHIT - Answer- Registered Health Information Technician RHIA - Answer- Registered Health Information Administrator CCS - Answer- Certified Coding Specialist RN - Answer- Registered Nurse Clinical documentation specialists can be - Answer- RHITs, RHIAs, CCS, or RNs CDI - Answer- Clinical Docume