Tennessee Clinical Documentation
Improvement Exam Question and correct
answers (verified answers 100%)
Q&A 2026/2027 INSTANT DOWNLOAD PDF
1. What is the primary goal of a Clinical Documentation Improvement (CDI)
program?
A. Increase hospital charges
B. Improve accuracy and completeness of clinical documentation
C. Replace medical coders
D. Reduce physician workload
Correct Answer: B
CDI programs ensure that patient records accurately reflect the patient's clinical
conditions, treatments, and complexity to support quality reporting, coding
accuracy, and appropriate reimbursement.
2. Which organization publishes the Official Guidelines for Coding and Reporting
used by CDI professionals?
A. OSHA
B. CMS
C. Cooperating Parties (AHA, AHIMA, CMS, NCHS)
D. FDA
Correct Answer: C
,The Official Guidelines for Coding and Reporting are developed through
cooperation among CMS, NCHS, AHA, and AHIMA.
3. A CDI specialist identifies that documentation states “acute kidney injury” but
lacks clinical indicators. What should the CDI specialist do?
A. Assign the diagnosis independently
B. Delete the diagnosis
C. Review clinical indicators and query when appropriate
D. Change the diagnosis code
Correct Answer: C
CDI specialists cannot independently diagnose patients. They review
documentation and clinical evidence and may issue compliant queries.
4. Which document is considered the legal record of the patient’s hospital stay?
A. Billing claim
B. Medical record
C. CDI worksheet
D. Coding summary
Correct Answer: B
The medical record is the legal documentation of patient care and must accurately
reflect diagnoses and treatments.
5. What does SOI stand for in CDI?
A. Severity of Illness
B. Standard Operating Instructions
C. Summary of Insurance
D. System of Integration
,Correct Answer: A
Severity of Illness measures the extent of a patient's disease burden and resource
utilization.
6. What does ROM represent in healthcare documentation?
A. Risk of Mortality
B. Rate of Medication
C. Record of Management
D. Response Outcome Measure
Correct Answer: A
Risk of Mortality reflects the likelihood of death based on patient conditions and
severity.
7. Which healthcare payment system is primarily affected by accurate CDI
documentation in inpatient hospitals?
A. Fee-for-service only
B. MS-DRG system
C. Workers compensation
D. Retail pharmacy billing
Correct Answer: B
Medicare Severity Diagnosis Related Groups (MS-DRGs) use documented
diagnoses and procedures to determine payment.
8. A CDI query should always be:
A. Leading toward a higher-paying diagnosis
B. Clinically supported and compliant
, C. Written only by physicians
D. Used for every patient encounter
Correct Answer: B
Queries must be based on clinical indicators and should seek clarification without
influencing the provider’s decision.
9. Which organization provides CDI certification programs commonly used by
professionals?
A. AHIMA
B. EPA
C. DEA
D. OSHA
Correct Answer: A
AHIMA offers CDI education and certification programs for healthcare
documentation professionals.
10. What is the purpose of a compliant physician query?
A. Increase reimbursement regardless of documentation
B. Obtain clarification of incomplete or conflicting documentation
C. Replace physician notes
D. Correct patient errors
Correct Answer: B
Queries help clarify ambiguous, incomplete, or inconsistent clinical
documentation.
11. Which diagnosis usually requires additional documentation clarification?
Improvement Exam Question and correct
answers (verified answers 100%)
Q&A 2026/2027 INSTANT DOWNLOAD PDF
1. What is the primary goal of a Clinical Documentation Improvement (CDI)
program?
A. Increase hospital charges
B. Improve accuracy and completeness of clinical documentation
C. Replace medical coders
D. Reduce physician workload
Correct Answer: B
CDI programs ensure that patient records accurately reflect the patient's clinical
conditions, treatments, and complexity to support quality reporting, coding
accuracy, and appropriate reimbursement.
2. Which organization publishes the Official Guidelines for Coding and Reporting
used by CDI professionals?
A. OSHA
B. CMS
C. Cooperating Parties (AHA, AHIMA, CMS, NCHS)
D. FDA
Correct Answer: C
,The Official Guidelines for Coding and Reporting are developed through
cooperation among CMS, NCHS, AHA, and AHIMA.
3. A CDI specialist identifies that documentation states “acute kidney injury” but
lacks clinical indicators. What should the CDI specialist do?
A. Assign the diagnosis independently
B. Delete the diagnosis
C. Review clinical indicators and query when appropriate
D. Change the diagnosis code
Correct Answer: C
CDI specialists cannot independently diagnose patients. They review
documentation and clinical evidence and may issue compliant queries.
4. Which document is considered the legal record of the patient’s hospital stay?
A. Billing claim
B. Medical record
C. CDI worksheet
D. Coding summary
Correct Answer: B
The medical record is the legal documentation of patient care and must accurately
reflect diagnoses and treatments.
5. What does SOI stand for in CDI?
A. Severity of Illness
B. Standard Operating Instructions
C. Summary of Insurance
D. System of Integration
,Correct Answer: A
Severity of Illness measures the extent of a patient's disease burden and resource
utilization.
6. What does ROM represent in healthcare documentation?
A. Risk of Mortality
B. Rate of Medication
C. Record of Management
D. Response Outcome Measure
Correct Answer: A
Risk of Mortality reflects the likelihood of death based on patient conditions and
severity.
7. Which healthcare payment system is primarily affected by accurate CDI
documentation in inpatient hospitals?
A. Fee-for-service only
B. MS-DRG system
C. Workers compensation
D. Retail pharmacy billing
Correct Answer: B
Medicare Severity Diagnosis Related Groups (MS-DRGs) use documented
diagnoses and procedures to determine payment.
8. A CDI query should always be:
A. Leading toward a higher-paying diagnosis
B. Clinically supported and compliant
, C. Written only by physicians
D. Used for every patient encounter
Correct Answer: B
Queries must be based on clinical indicators and should seek clarification without
influencing the provider’s decision.
9. Which organization provides CDI certification programs commonly used by
professionals?
A. AHIMA
B. EPA
C. DEA
D. OSHA
Correct Answer: A
AHIMA offers CDI education and certification programs for healthcare
documentation professionals.
10. What is the purpose of a compliant physician query?
A. Increase reimbursement regardless of documentation
B. Obtain clarification of incomplete or conflicting documentation
C. Replace physician notes
D. Correct patient errors
Correct Answer: B
Queries help clarify ambiguous, incomplete, or inconsistent clinical
documentation.
11. Which diagnosis usually requires additional documentation clarification?
