CDIP COMPREHENSIVE EXAMS QUESTIONS AND
ANSWERS SET A+
✔✔Leaders may utilize this to view and report outcomes measures; sometimes called
Scorecard:
a.Snapshot
b.Dashboard
c.Score report
d.Query card - ✔✔b Scorecards are reports of outcomes measures to help leaders
know what they have accomplished; Also called dashboards (AHIMA 2014a, 26).
✔✔Three quality measures that can be immediately impacted by the implementation of
a CDI program are present on admission (POA), hospital-acquired conditions (HACs),
and
a.Major complications and comorbid conditions (MCCs)
b.ICD-10-CM coding
c.Physician quality reporting
d.Length of stay - ✔✔a CDI is gradually expanding to quality. Three quality measures
that can be immediately impacted by the implementation of a CDI program are Present
on admission (POA), Hospital-acquired conditions (HACs), and Major complications and
comorbid conditions (MCCs) (Wiedemann 2013, 44-45).
✔✔Retention of queries should be established with the assistance of the facility:
a.CEO
b.Legal counsel
c.Director of nursing
d.Chief information officer - ✔✔b The retention of queries should be determined utilizing
the advice of legal counsel and outlined in the policies and procedures (AHIMA 2014a,
5, 14).
✔✔A new nursing or HIM graduate may not be the right candidate for a CDI position at
a large quaternary care center due to:
a.Lack of basic coding knowledge
,b.Lack of experience with clinical concepts
c.Both a and b
d.None of the above - ✔✔c The CDI specialists should have a clinical or health
information background with record review experience. They should be able to
effectively communicate with physicians and skillfully review clinical documentation to
determine where it fails to meet the criteria for high quality (Hess 2015, 129).
✔✔In performing query reconciliation, it is determined that queries initiated on the floor
in the concurrent process are not addressed retrospectively at discharge. This is:
a.appropriate, as queries should not be made retrospectively
b.appropriate, as queries should not be a concern once the patient is discharged
c.inappropriate, as queries should be generated or addressed by the coder
retrospectively
d.a non-issue, as it never happens - ✔✔c The most efficient way to capture
retrospective queries is through the coding process Therefore, it is essential to have the
coding staff interface with the CDI program staff. The coding staff should understand
when there are outstanding concurrent queries upon discharge of the patient. The
coding professional should generate a retrospective query to the physician so long as
the justification for the query still exists when the patient is discharged (Hess 2015,
131).
✔✔Physicians within this group are often considered top priority for CDI training:
a.Oncologists
b.Neurologists
c.Hospitalists
d.Cardiologists - ✔✔c Physicians from the hospitalist group are often the top priority for
CDI training in many organizations. Hospitalists often take on the role of the patient's
primary care physician when a patient is hospitalized. Hospitalists should therefore have
a predominant role in CDI training (Hess 2015, 146).
✔✔The interactive process of utilizing a physician trainer to share experiences about
clinical documentation with the trainees is:
a.Asking
b.Training
c.Mastering
d.Coaching - ✔✔d Coaching is important for reinforcement and encouragement of
participants within a CDI program. Experiences are shared, feedback is obtained and
activities reinforced (Hess 2015, 147).
✔✔The director of CDI and Coding is trying to improve communication between the
CDI, physicians, and coding staff. A process is being developed to integrate the CDI
model with the EHR to correspond with the physician for clarifications regarding
documentation. This is called a:
a.Electronic Query Process
b.EHR innovation
, c.Electronic Documentation Integrity
d.Meaningful Use - ✔✔a The Electronic Query process is being utilized in many
facilities to streamline the query process and make queries more readily accessible
remotely (AHIMA 2014a, 5).
✔✔A CDI program should have
a.Training
b.Physician advisor or champion
c.Nurses or coders performing CDI review
d.None of the above - ✔✔b A physician advisor/champion should be officially
designated as the physician leader for CDI (Hess 2015, 122).
✔✔ABC Hospital has secured a consultant in making the decision to implement a CDI
program. The consulting group has determined a CDI program can impact 70 percent of
the MSDRG population and 90 percent of the medical staff could benefit from CDI
initiatives. This analysis is
a.Not necessary in making a decision for CDI
b.Important in assisting organizations in identifying potential benefits.
c.Does not show impact of the need for CDI
d.Unnecessary based on the needs - ✔✔b Collecting complete and accurate data prior
to program implementation can assist organizations in identifying potential benefits
(AHIMA 2014a, 11).
✔✔The first great challenge of a CDI program is to
a.Persuade and have the full support of administration to implement and sustain the
CDI program
b.Find qualified staff for the program
c.Engage medical staff
d.Show quarterly return on investment - ✔✔a The first great challenge of a CDI program
is to persuade and have the full support of administration to implement and sustain the
CDI program (AHIMA 2014a, 12).
✔✔The CDS specialist, Gem, at ABC Hospital has had little success with several
physicians responding to clinical validation queries. A colleague of Gem's mentioned
she should share this process with her manager. The colleague most likely was
referring to
a.Clinical policy
b.Query policy
c.Escalation policy
d.Physician Code of Ethics - ✔✔c The AHIMA-developed Internal Escalation Policy
includes sample policies that require a CDI specialist or coder to escalate issues
regarding clinical documentation validity to a manager or steering committee (AHIMA
2013a, 1).
ANSWERS SET A+
✔✔Leaders may utilize this to view and report outcomes measures; sometimes called
Scorecard:
a.Snapshot
b.Dashboard
c.Score report
d.Query card - ✔✔b Scorecards are reports of outcomes measures to help leaders
know what they have accomplished; Also called dashboards (AHIMA 2014a, 26).
✔✔Three quality measures that can be immediately impacted by the implementation of
a CDI program are present on admission (POA), hospital-acquired conditions (HACs),
and
a.Major complications and comorbid conditions (MCCs)
b.ICD-10-CM coding
c.Physician quality reporting
d.Length of stay - ✔✔a CDI is gradually expanding to quality. Three quality measures
that can be immediately impacted by the implementation of a CDI program are Present
on admission (POA), Hospital-acquired conditions (HACs), and Major complications and
comorbid conditions (MCCs) (Wiedemann 2013, 44-45).
✔✔Retention of queries should be established with the assistance of the facility:
a.CEO
b.Legal counsel
c.Director of nursing
d.Chief information officer - ✔✔b The retention of queries should be determined utilizing
the advice of legal counsel and outlined in the policies and procedures (AHIMA 2014a,
5, 14).
✔✔A new nursing or HIM graduate may not be the right candidate for a CDI position at
a large quaternary care center due to:
a.Lack of basic coding knowledge
,b.Lack of experience with clinical concepts
c.Both a and b
d.None of the above - ✔✔c The CDI specialists should have a clinical or health
information background with record review experience. They should be able to
effectively communicate with physicians and skillfully review clinical documentation to
determine where it fails to meet the criteria for high quality (Hess 2015, 129).
✔✔In performing query reconciliation, it is determined that queries initiated on the floor
in the concurrent process are not addressed retrospectively at discharge. This is:
a.appropriate, as queries should not be made retrospectively
b.appropriate, as queries should not be a concern once the patient is discharged
c.inappropriate, as queries should be generated or addressed by the coder
retrospectively
d.a non-issue, as it never happens - ✔✔c The most efficient way to capture
retrospective queries is through the coding process Therefore, it is essential to have the
coding staff interface with the CDI program staff. The coding staff should understand
when there are outstanding concurrent queries upon discharge of the patient. The
coding professional should generate a retrospective query to the physician so long as
the justification for the query still exists when the patient is discharged (Hess 2015,
131).
✔✔Physicians within this group are often considered top priority for CDI training:
a.Oncologists
b.Neurologists
c.Hospitalists
d.Cardiologists - ✔✔c Physicians from the hospitalist group are often the top priority for
CDI training in many organizations. Hospitalists often take on the role of the patient's
primary care physician when a patient is hospitalized. Hospitalists should therefore have
a predominant role in CDI training (Hess 2015, 146).
✔✔The interactive process of utilizing a physician trainer to share experiences about
clinical documentation with the trainees is:
a.Asking
b.Training
c.Mastering
d.Coaching - ✔✔d Coaching is important for reinforcement and encouragement of
participants within a CDI program. Experiences are shared, feedback is obtained and
activities reinforced (Hess 2015, 147).
✔✔The director of CDI and Coding is trying to improve communication between the
CDI, physicians, and coding staff. A process is being developed to integrate the CDI
model with the EHR to correspond with the physician for clarifications regarding
documentation. This is called a:
a.Electronic Query Process
b.EHR innovation
, c.Electronic Documentation Integrity
d.Meaningful Use - ✔✔a The Electronic Query process is being utilized in many
facilities to streamline the query process and make queries more readily accessible
remotely (AHIMA 2014a, 5).
✔✔A CDI program should have
a.Training
b.Physician advisor or champion
c.Nurses or coders performing CDI review
d.None of the above - ✔✔b A physician advisor/champion should be officially
designated as the physician leader for CDI (Hess 2015, 122).
✔✔ABC Hospital has secured a consultant in making the decision to implement a CDI
program. The consulting group has determined a CDI program can impact 70 percent of
the MSDRG population and 90 percent of the medical staff could benefit from CDI
initiatives. This analysis is
a.Not necessary in making a decision for CDI
b.Important in assisting organizations in identifying potential benefits.
c.Does not show impact of the need for CDI
d.Unnecessary based on the needs - ✔✔b Collecting complete and accurate data prior
to program implementation can assist organizations in identifying potential benefits
(AHIMA 2014a, 11).
✔✔The first great challenge of a CDI program is to
a.Persuade and have the full support of administration to implement and sustain the
CDI program
b.Find qualified staff for the program
c.Engage medical staff
d.Show quarterly return on investment - ✔✔a The first great challenge of a CDI program
is to persuade and have the full support of administration to implement and sustain the
CDI program (AHIMA 2014a, 12).
✔✔The CDS specialist, Gem, at ABC Hospital has had little success with several
physicians responding to clinical validation queries. A colleague of Gem's mentioned
she should share this process with her manager. The colleague most likely was
referring to
a.Clinical policy
b.Query policy
c.Escalation policy
d.Physician Code of Ethics - ✔✔c The AHIMA-developed Internal Escalation Policy
includes sample policies that require a CDI specialist or coder to escalate issues
regarding clinical documentation validity to a manager or steering committee (AHIMA
2013a, 1).
