Question 1
Which member of the clinical documentation integrity (CDI) team can help provide peer-to-peer
level of education on the importance of accurate documentation and query responses?
A.Chief Financial Officer
B.Physician advisor/champion
C.CDI practitioner
D.CDI manager
Correct Answer: B
Explanation
The member of the clinical documentation integrity (CDI) team who can help provide peer-to-
peer level of education on the importance of accurate documentation and query responses is the
physician advisor/champion. The physician advisor/champion is a physician who supports and
advocates for the CDI program and its goals, and who can communicate effectively with other
physicians about the clinical and financial implications of documentation quality and accuracy.
The physician advisor/champion can also serve as a liaison between the CDI team and the
medical staff, and help to resolve any issues or conflicts that may arise from the query process.
The physician advisor/champion can also provide feedback and guidance to the CDI team on
clinical matters and documentation standards. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Question 2
A patient's progress note states "The patient has chronic systolic heart failure". After reviewing
clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical
documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of
the diagnosis. Which subsequent documentation in the health record suggests the provider did
not understand the query?
A.The patient has chronic systolic heart failure.
B.The patient has acute on chronic systolic heart failure.
C.The patient did have an exacerbation of heart failure.
D.The patient has decompensated systolic heart failure.
Correct Answer: A
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or
process used to clarify documentation in the health record for documentation integrity and
accurate code assignment1. A query should be clear, concise, and consistent, and should include
relevant clinical indicators that support the query1. A query should also provide multiple choice
answer options that are supported by clinical indicators and include a non-leading query
statement2. In this case, the CDIP queried the physician to clarify the current acuity of the
diagnosis of chronic systolic heart failure, based on clinical indicators suggestive of an
exacerbation of systolic heart failure. The subsequent documentation in the health record that
suggests the provider did not understand the query is A. The patient has chronic systolic heart
,failure. This documentation does not address the query or provide any additional information
about the patient's condition. It simply repeats the same diagnosis that was already documented
in the progress note. This documentation does not reflect the patient's true severity of illness, risk
of mortality, or reimbursement3. The other options are not correct because they do provide some
information about the current acuity of the diagnosis of chronic systolic heart failure, such as
acute on chronic, exacerbation, or decompensation. These terms indicate a higher level of
severity and complexity than chronic alone. References:
CDIP Exam Preparation Guide - AHIMA
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Severity of
Illness: What Is It? Why Is It Important? | HCPro
[Q&A: Acute on chronic versus decompensated heart failure | ACDIS]
Question 3
A query should be generated when the documentation is
A.legible
B.consistent
C.complete
D.conflicting
Correct Answer: D
Explanation
A query should be generated when the documentation is conflicting, meaning that there is
contradictory or inconsistent information in the medical record that may affect the accuracy of
coding, quality reporting, or reimbursement. For example, if the documentation in the progress
notes differs from the documentation in the discharge summary, or if different providers
document different diagnoses or procedures for the same patient, a query may be needed to
resolve the discrepancy and obtain clarification from the source of the documentation. A query
should not be generated when the documentation is legible, consistent, or complete, as these are
desirable characteristics of documentation that do not require further clarification or verification.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-
outline.pdf) Accurate Documentation is Essential - Knowing When to Query your Providers1
Question 4
A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower
extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram
was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's
history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular
filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity
practitioner (CDIP) has queried the physician to further clarify the patient's diagnosis. Which
response provides the highest level of specificity?
A.Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
B.Acute on chronic systolic CHF with hypertensive renal disease, CKD 3
C.Acute diastolic CHF with HTN and CKD 3
, D.Acute CHF with hypertensive renal disease, CKD 3
Correct Answer: A
Explanation
This response provides the highest level of specificity for the patient's diagnosis because it
includes the following elements:
The type of heart failure: diastolic, which means the heart has difficulty relaxing and filling with
blood during diastole, resulting in increased filling pressures and pulmonary congestion.
Diastolic heart failure is also known as heart failure with preserved ejection fraction (HFpEF),
which is defined as an ejection fraction of 50% or higher 2.
The acuity of heart failure: acute on chronic, which means the patient has a history of chronic
heart failure that has worsened acutely due to a precipitating factor, such as infection, ischemia,
arrhythmia, or medication noncompliance. Acute on chronic heart failure is associated with
higher mortality and morbidity than stable chronic heart failure 3.
The associated conditions: hypertensive renal disease and CKD 3, which indicate that the patient
has kidney damage and reduced kidney function due to high blood pressure. CKD 3 is the third
stage of chronic kidney disease, which is characterized by a glomerular filtration rate of 30 to 59
mL per minute per 1.73 m2 4.
The other responses are less specific because they either omit or misrepresent some of these
elements. For example, response B incorrectly states that the patient has systolic heart failure,
which is contradicted by the echocardiogram result. Response C does not specify whether the
heart failure is chronic or acute on chronic, which has implications for treatment and prognosis.
Response D does not specify the type of heart failure, which affects the coding and classification
of the condition.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 5 2: Heart Failure With
Preserved Ejection Fraction (HFpEF) | American Heart Association 3: Acute-on-Chronic Heart
Failure: A High-Risk Phenotype Needing Separate Attention 4: Chronic Kidney Disease (CKD) |
National Kidney Foundation
Question 5
Which of the following clinical documentation integrity (CDI) dashboard metrics is frequently
used to help evaluate the credibility of CDI practitioner queries and the success of the CDI
program?
A.CDI agreement rate
B.CDI query rate
C.Provider response rate
D.Provider agreement rate
Correct Answer: D
Explanation
The provider agreement rate is the percentage of queries that result in a change in the
documentation or coding that is consistent with the query. It is a measure of the accuracy and
appropriateness of the queries, as well as the provider's acceptance of the CDI program's
recommendations. A high provider agreement rate indicates that the CDI practitioners are asking
relevant and compliant queries that improve the quality and specificity of the documentation.
The other options are not directly related to the credibility of the queries or the success of the
CDI program. The CDI agreement rate is the percentage of queries that agree with the coder's
Which member of the clinical documentation integrity (CDI) team can help provide peer-to-peer
level of education on the importance of accurate documentation and query responses?
A.Chief Financial Officer
B.Physician advisor/champion
C.CDI practitioner
D.CDI manager
Correct Answer: B
Explanation
The member of the clinical documentation integrity (CDI) team who can help provide peer-to-
peer level of education on the importance of accurate documentation and query responses is the
physician advisor/champion. The physician advisor/champion is a physician who supports and
advocates for the CDI program and its goals, and who can communicate effectively with other
physicians about the clinical and financial implications of documentation quality and accuracy.
The physician advisor/champion can also serve as a liaison between the CDI team and the
medical staff, and help to resolve any issues or conflicts that may arise from the query process.
The physician advisor/champion can also provide feedback and guidance to the CDI team on
clinical matters and documentation standards. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Question 2
A patient's progress note states "The patient has chronic systolic heart failure". After reviewing
clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical
documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of
the diagnosis. Which subsequent documentation in the health record suggests the provider did
not understand the query?
A.The patient has chronic systolic heart failure.
B.The patient has acute on chronic systolic heart failure.
C.The patient did have an exacerbation of heart failure.
D.The patient has decompensated systolic heart failure.
Correct Answer: A
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or
process used to clarify documentation in the health record for documentation integrity and
accurate code assignment1. A query should be clear, concise, and consistent, and should include
relevant clinical indicators that support the query1. A query should also provide multiple choice
answer options that are supported by clinical indicators and include a non-leading query
statement2. In this case, the CDIP queried the physician to clarify the current acuity of the
diagnosis of chronic systolic heart failure, based on clinical indicators suggestive of an
exacerbation of systolic heart failure. The subsequent documentation in the health record that
suggests the provider did not understand the query is A. The patient has chronic systolic heart
,failure. This documentation does not address the query or provide any additional information
about the patient's condition. It simply repeats the same diagnosis that was already documented
in the progress note. This documentation does not reflect the patient's true severity of illness, risk
of mortality, or reimbursement3. The other options are not correct because they do provide some
information about the current acuity of the diagnosis of chronic systolic heart failure, such as
acute on chronic, exacerbation, or decompensation. These terms indicate a higher level of
severity and complexity than chronic alone. References:
CDIP Exam Preparation Guide - AHIMA
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Severity of
Illness: What Is It? Why Is It Important? | HCPro
[Q&A: Acute on chronic versus decompensated heart failure | ACDIS]
Question 3
A query should be generated when the documentation is
A.legible
B.consistent
C.complete
D.conflicting
Correct Answer: D
Explanation
A query should be generated when the documentation is conflicting, meaning that there is
contradictory or inconsistent information in the medical record that may affect the accuracy of
coding, quality reporting, or reimbursement. For example, if the documentation in the progress
notes differs from the documentation in the discharge summary, or if different providers
document different diagnoses or procedures for the same patient, a query may be needed to
resolve the discrepancy and obtain clarification from the source of the documentation. A query
should not be generated when the documentation is legible, consistent, or complete, as these are
desirable characteristics of documentation that do not require further clarification or verification.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-
outline.pdf) Accurate Documentation is Essential - Knowing When to Query your Providers1
Question 4
A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower
extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram
was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's
history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular
filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity
practitioner (CDIP) has queried the physician to further clarify the patient's diagnosis. Which
response provides the highest level of specificity?
A.Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
B.Acute on chronic systolic CHF with hypertensive renal disease, CKD 3
C.Acute diastolic CHF with HTN and CKD 3
, D.Acute CHF with hypertensive renal disease, CKD 3
Correct Answer: A
Explanation
This response provides the highest level of specificity for the patient's diagnosis because it
includes the following elements:
The type of heart failure: diastolic, which means the heart has difficulty relaxing and filling with
blood during diastole, resulting in increased filling pressures and pulmonary congestion.
Diastolic heart failure is also known as heart failure with preserved ejection fraction (HFpEF),
which is defined as an ejection fraction of 50% or higher 2.
The acuity of heart failure: acute on chronic, which means the patient has a history of chronic
heart failure that has worsened acutely due to a precipitating factor, such as infection, ischemia,
arrhythmia, or medication noncompliance. Acute on chronic heart failure is associated with
higher mortality and morbidity than stable chronic heart failure 3.
The associated conditions: hypertensive renal disease and CKD 3, which indicate that the patient
has kidney damage and reduced kidney function due to high blood pressure. CKD 3 is the third
stage of chronic kidney disease, which is characterized by a glomerular filtration rate of 30 to 59
mL per minute per 1.73 m2 4.
The other responses are less specific because they either omit or misrepresent some of these
elements. For example, response B incorrectly states that the patient has systolic heart failure,
which is contradicted by the echocardiogram result. Response C does not specify whether the
heart failure is chronic or acute on chronic, which has implications for treatment and prognosis.
Response D does not specify the type of heart failure, which affects the coding and classification
of the condition.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 5 2: Heart Failure With
Preserved Ejection Fraction (HFpEF) | American Heart Association 3: Acute-on-Chronic Heart
Failure: A High-Risk Phenotype Needing Separate Attention 4: Chronic Kidney Disease (CKD) |
National Kidney Foundation
Question 5
Which of the following clinical documentation integrity (CDI) dashboard metrics is frequently
used to help evaluate the credibility of CDI practitioner queries and the success of the CDI
program?
A.CDI agreement rate
B.CDI query rate
C.Provider response rate
D.Provider agreement rate
Correct Answer: D
Explanation
The provider agreement rate is the percentage of queries that result in a change in the
documentation or coding that is consistent with the query. It is a measure of the accuracy and
appropriateness of the queries, as well as the provider's acceptance of the CDI program's
recommendations. A high provider agreement rate indicates that the CDI practitioners are asking
relevant and compliant queries that improve the quality and specificity of the documentation.
The other options are not directly related to the credibility of the queries or the success of the
CDI program. The CDI agreement rate is the percentage of queries that agree with the coder's
