CDIP EXAM 300 ACTUAL QUESTIONS AND
CORRECT ANSWERS WITH RATIONALE
LATEST UPDATE ALREADY GRADED A+
1. A clinical documentation integrity practitioner (CDIP) is reviewing a record
where the physician documented "acute respiratory failure" but the clinical
indicators in the record do not support the diagnosis. What is the most appropriate
action?
A) Query the physician to provide clinical validation for the diagnosis
B) Assign the code for acute respiratory failure based on the physician statement
alone
C) Ignore the diagnosis and code only the conditions with supporting
documentation
D) Assign the code for acute respiratory failure but add a query for clarification
Correct Answer: A) Query the physician to provide clinical validation for the
diagnosis
Rationale: Clinical validation queries are essential when the documentation does
not adequately support the clinical indicators for a diagnosis. The CDIP must
ensure that the diagnosis is supported by clinical evidence in the record before
code assignment. Ethical coding practices require that diagnoses are supported by
clinical documentation.
2. A CDIP is reviewing a case where the physician documented "pneumonia" but
the patient's WBC is 20,000, respiratory rate is 20, heart rate is 85, and oral
temperature is 99.0°F. On day 2, sputum cultures reveal positive results for
pseudomonas bacteria. What is the most appropriate action?
A) Code pneumonia, unspecified
B) Query the provider to see if pseudomonas sepsis is supported by the health
record
C) Code pseudomonas pneumonia
D) Query the provider to document the etiology of pneumonia
Correct Answer: D) Query the provider to document the etiology of pneumonia
,Rationale: The positive pseudomonas sputum culture indicates a specific etiology,
and the provider should be queried to document the specific type of pneumonia.
This ensures accurate and specific code assignment rather than assigning an
unspecified code.
3. A CDIP generates a concurrent query, and the coder releases the bill before the
query is answered. The physician answers the query after the bill has dropped.
Which policy should the hospital follow to avoid a compliance risk?
A) A rebilling is permissible when queries are answered after the initial bill
B) A post-bill query rarely occurs as a result of an audit of other internal monitor
C) A post-bill query is not appropriate when an error is found after an audit
D) A second bill should not be submitted when the first bill was incomplete
Correct Answer: A) A rebilling is permissible when queries are answered after the
initial bill
Rationale: Post-bill queries that result in changed diagnoses or procedures may
justify a rebilling if the initial bill was incomplete or incorrect. The hospital should
have a formal policy regarding post-bill query responses to ensure compliance and
avoid risk.
4. Which of the following can be evidence of physician-hospital alignment?
A) A high clinical documentation integrity practitioner (CDIP) query rate
B) A high physician agreement rate
C) A high physician response rate
D) A low physician agreement rate
Correct Answer: C) A high physician response rate
Rationale: A high physician response rate to queries indicates strong engagement
and alignment with the CDI program. It suggests that physicians understand the
importance of accurate documentation and are actively participating in the process.
5. A CDIP is reviewing a record for a patient with sepsis. The physician has
documented "sepsis" but has not documented the specific organism. What is the
most appropriate action?
A) Query the physician to identify the specific organism causing the sepsis
B) Code sepsis without the organism since it is not specified
C) Code sepsis with the organism based on the laboratory findings
D) Assign a code for systemic inflammatory response syndrome (SIRS)
Correct Answer: A) Query the physician to identify the specific organism causing
the sepsis
Rationale: Accurate coding of sepsis requires the specific organism to be
documented by the physician. While laboratory findings may suggest an organism,
,the physician must document the diagnosis and the causative organism for coding
purposes.
6. A CDI program is being developed in a hospital. Which of the following is the
most important first step?
A) Hiring a CDI manager
B) Conducting a needs assessment and gaining leadership support
C) Implementing a physician query process
D) Purchasing CDI software
Correct Answer: B) Conducting a needs assessment and gaining leadership support
Rationale: Leadership support is crucial for the success of a CDI program. An
administrative champion helps secure resources and drives physician engagement,
which are essential for the program's development and sustainability.
7. A physician consistently fails to respond to CDI queries. What is the most
appropriate initial action by the CDIP?
A) Escalate the issue directly to the hospital's compliance officer
B) Implement consequences for non-compliance to queries
C) Collaborate with the physician champion to address the issue
D) Discontinue sending queries to that physician
Correct Answer: C) Collaborate with the physician champion to address the issue
Rationale: Physician champions are key advocates who can influence peers.
Collaborating with a champion is often an effective first step to improve response
rates before implementing formal consequences.
8. A CDIP is reviewing a record and notes that the physician has documented
"hypertensive crisis." What is the most appropriate action?
A) Query the physician to specify the type of hypertension
B) Code hypertensive crisis with the appropriate code
C) Query the physician to document the clinical indicators supporting the diagnosis
D) Ignore the diagnosis and code the underlying conditions
Correct Answer: C) Query the physician to document the clinical indicators
supporting the diagnosis
Rationale: Hypertensive crisis should be validated by clinical indicators such as
blood pressure levels and symptoms. Querying the physician to document the
clinical indicators ensures the diagnosis is supported before code assignment.
9. A CDI program is considered successful when:
A) Query rates are at their highest
B) Physician query response times are minimal
, C) Accurate and complete documentation supports quality, safety, and
reimbursement
D) The number of denials increases
Correct Answer: C) Accurate and complete documentation supports quality, safety,
and reimbursement
Rationale: The primary goal of a CDI program is to improve documentation
accuracy and completeness, which supports quality patient care, safety, and
appropriate reimbursement. High query rates alone do not indicate success.
10. A CDIP is educating a new physician about the importance of clinical
documentation improvement. What is the most effective approach?
A) Focus on the financial benefits of accurate documentation
B) Explain how accurate documentation supports patient care and quality
outcomes
C) Provide a list of common coding errors
D) Offer a one-time training session
Correct Answer: B) Explain how accurate documentation supports patient care and
quality outcomes
Rationale: Physicians are often more receptive to education that emphasizes patient
care and quality outcomes rather than just financial incentives. A focus on clinical
relevance improves engagement and understanding.
11. A CDIP is performing a retrospective audit of physician query responses. The
purpose of this audit is to:
A) Determine the number of queries sent
B) Ensure compliance with documentation standards and identify areas for
improvement
C) Identify physicians who are non-compliant
D) Calculate the financial impact of documentation
Correct Answer: B) Ensure compliance with documentation standards and identify
areas for improvement
Rationale: Auditing query responses helps ensure that the CDI program is effective
and that documentation standards are being met. It also identifies areas where
physician education may be needed.
12. A physician documents a diagnosis that is not supported by the clinical
indicators in the record. This is an example of:
A) Query opportunity
B) A valid clinical diagnosis
C) An ethical documentation practice
CORRECT ANSWERS WITH RATIONALE
LATEST UPDATE ALREADY GRADED A+
1. A clinical documentation integrity practitioner (CDIP) is reviewing a record
where the physician documented "acute respiratory failure" but the clinical
indicators in the record do not support the diagnosis. What is the most appropriate
action?
A) Query the physician to provide clinical validation for the diagnosis
B) Assign the code for acute respiratory failure based on the physician statement
alone
C) Ignore the diagnosis and code only the conditions with supporting
documentation
D) Assign the code for acute respiratory failure but add a query for clarification
Correct Answer: A) Query the physician to provide clinical validation for the
diagnosis
Rationale: Clinical validation queries are essential when the documentation does
not adequately support the clinical indicators for a diagnosis. The CDIP must
ensure that the diagnosis is supported by clinical evidence in the record before
code assignment. Ethical coding practices require that diagnoses are supported by
clinical documentation.
2. A CDIP is reviewing a case where the physician documented "pneumonia" but
the patient's WBC is 20,000, respiratory rate is 20, heart rate is 85, and oral
temperature is 99.0°F. On day 2, sputum cultures reveal positive results for
pseudomonas bacteria. What is the most appropriate action?
A) Code pneumonia, unspecified
B) Query the provider to see if pseudomonas sepsis is supported by the health
record
C) Code pseudomonas pneumonia
D) Query the provider to document the etiology of pneumonia
Correct Answer: D) Query the provider to document the etiology of pneumonia
,Rationale: The positive pseudomonas sputum culture indicates a specific etiology,
and the provider should be queried to document the specific type of pneumonia.
This ensures accurate and specific code assignment rather than assigning an
unspecified code.
3. A CDIP generates a concurrent query, and the coder releases the bill before the
query is answered. The physician answers the query after the bill has dropped.
Which policy should the hospital follow to avoid a compliance risk?
A) A rebilling is permissible when queries are answered after the initial bill
B) A post-bill query rarely occurs as a result of an audit of other internal monitor
C) A post-bill query is not appropriate when an error is found after an audit
D) A second bill should not be submitted when the first bill was incomplete
Correct Answer: A) A rebilling is permissible when queries are answered after the
initial bill
Rationale: Post-bill queries that result in changed diagnoses or procedures may
justify a rebilling if the initial bill was incomplete or incorrect. The hospital should
have a formal policy regarding post-bill query responses to ensure compliance and
avoid risk.
4. Which of the following can be evidence of physician-hospital alignment?
A) A high clinical documentation integrity practitioner (CDIP) query rate
B) A high physician agreement rate
C) A high physician response rate
D) A low physician agreement rate
Correct Answer: C) A high physician response rate
Rationale: A high physician response rate to queries indicates strong engagement
and alignment with the CDI program. It suggests that physicians understand the
importance of accurate documentation and are actively participating in the process.
5. A CDIP is reviewing a record for a patient with sepsis. The physician has
documented "sepsis" but has not documented the specific organism. What is the
most appropriate action?
A) Query the physician to identify the specific organism causing the sepsis
B) Code sepsis without the organism since it is not specified
C) Code sepsis with the organism based on the laboratory findings
D) Assign a code for systemic inflammatory response syndrome (SIRS)
Correct Answer: A) Query the physician to identify the specific organism causing
the sepsis
Rationale: Accurate coding of sepsis requires the specific organism to be
documented by the physician. While laboratory findings may suggest an organism,
,the physician must document the diagnosis and the causative organism for coding
purposes.
6. A CDI program is being developed in a hospital. Which of the following is the
most important first step?
A) Hiring a CDI manager
B) Conducting a needs assessment and gaining leadership support
C) Implementing a physician query process
D) Purchasing CDI software
Correct Answer: B) Conducting a needs assessment and gaining leadership support
Rationale: Leadership support is crucial for the success of a CDI program. An
administrative champion helps secure resources and drives physician engagement,
which are essential for the program's development and sustainability.
7. A physician consistently fails to respond to CDI queries. What is the most
appropriate initial action by the CDIP?
A) Escalate the issue directly to the hospital's compliance officer
B) Implement consequences for non-compliance to queries
C) Collaborate with the physician champion to address the issue
D) Discontinue sending queries to that physician
Correct Answer: C) Collaborate with the physician champion to address the issue
Rationale: Physician champions are key advocates who can influence peers.
Collaborating with a champion is often an effective first step to improve response
rates before implementing formal consequences.
8. A CDIP is reviewing a record and notes that the physician has documented
"hypertensive crisis." What is the most appropriate action?
A) Query the physician to specify the type of hypertension
B) Code hypertensive crisis with the appropriate code
C) Query the physician to document the clinical indicators supporting the diagnosis
D) Ignore the diagnosis and code the underlying conditions
Correct Answer: C) Query the physician to document the clinical indicators
supporting the diagnosis
Rationale: Hypertensive crisis should be validated by clinical indicators such as
blood pressure levels and symptoms. Querying the physician to document the
clinical indicators ensures the diagnosis is supported before code assignment.
9. A CDI program is considered successful when:
A) Query rates are at their highest
B) Physician query response times are minimal
, C) Accurate and complete documentation supports quality, safety, and
reimbursement
D) The number of denials increases
Correct Answer: C) Accurate and complete documentation supports quality, safety,
and reimbursement
Rationale: The primary goal of a CDI program is to improve documentation
accuracy and completeness, which supports quality patient care, safety, and
appropriate reimbursement. High query rates alone do not indicate success.
10. A CDIP is educating a new physician about the importance of clinical
documentation improvement. What is the most effective approach?
A) Focus on the financial benefits of accurate documentation
B) Explain how accurate documentation supports patient care and quality
outcomes
C) Provide a list of common coding errors
D) Offer a one-time training session
Correct Answer: B) Explain how accurate documentation supports patient care and
quality outcomes
Rationale: Physicians are often more receptive to education that emphasizes patient
care and quality outcomes rather than just financial incentives. A focus on clinical
relevance improves engagement and understanding.
11. A CDIP is performing a retrospective audit of physician query responses. The
purpose of this audit is to:
A) Determine the number of queries sent
B) Ensure compliance with documentation standards and identify areas for
improvement
C) Identify physicians who are non-compliant
D) Calculate the financial impact of documentation
Correct Answer: B) Ensure compliance with documentation standards and identify
areas for improvement
Rationale: Auditing query responses helps ensure that the CDI program is effective
and that documentation standards are being met. It also identifies areas where
physician education may be needed.
12. A physician documents a diagnosis that is not supported by the clinical
indicators in the record. This is an example of:
A) Query opportunity
B) A valid clinical diagnosis
C) An ethical documentation practice
