CDI Question and Answer Key
What is a reason a physician documentation can be difficult to review? - verified answer Illegible
handwriting
The best scientific data available for clinical documentation is also known as - verified answer
Evidence-based medicine
The two-part theory for high-quality clinical documentation is a cause-and-effect theory that is
derived from which two sources? - verified answer Legal/Regulatory Sources and Peer-Reviewed
Research
When discussing completeness in a health record, the physician has fully addressed all concerns, as
well as what other authentication? - verified answer Signature and date
Peer-reviewed academic literature states that this factor shows a relationship to quality of care as
well as support for concurrent CDI programs: - verified answer Documentation
What evidence supports the lack of high-quality clinical documentation in the medical field? -
verified answer CDI is not taught in medical school
Which item is not recommended by the HHS and the OIG for minimum compliance with clinical
documentation regulations? - verified answer Physicians should include vaccination records
What does "reliable" in high-quality clinical documentation mean? - verified answer Physician
documentation supports medical treatment
Which item is an important aspect of consistent high-quality clinical documentation? - verified
answer Creates a clear picture for subsequent reviewers of documentation
Which aspect of the discharge summary is the biggest challenge to house staff, mid-level
practitioners, and attending physicians as they compose the patient's discharge summary? - verified
answer Timeliness
,Which aspect of the patient's health record can a member of the house staff or midlevel practitioner
create, yet ultimately needs the attending physician to confirm accuracy? - verified answer Problem
list
Interns, residents, and fellows are physicians with lesser accountability due to their inability to act as
an attending physician and are also known as ______. - verified answer House staff
Which two medical professionals serve as mid-level practitioners by supporting physicians in the
delivery of care? - verified answer Nurse practitioners and physician assistants
In 1982, which aspect of medical billing/reimbursement increased the demand for accuracy and
timeliness with regard to medical coding? - verified answer Reimbursement was driven by codes
assigned to patient care
Which hands-on provider's documentation should the coder not use for final coding? - verified
answer Diagnostic radiologist
Which practitioners, along with coding professionals, are proficient at picking up deficiencies in
clinical documentation yet must focus on giving care? - verified answer Nurses
Which healthcare setting requires high levels of proactivity from management and clinical teams to
ensure accurate and timely clinical documentation? - verified answer Outpatient
Which item is not an inpatient healthcare setting? - verified answer Emergency department
High-quality clinical documentation is the basis for what standard? - verified answer Gold standard
What allows the diagnostic, treatment, and response of information of the patient to be aggregated
into a uniform data set? - verified answer Coding
What part of the health record, usually located at the end the document, provides a complete
picture of the patient's diagnosis? - verified answer Impression and plan
What description is an aspect of the coding professionals' job? - verified answer Asking the physician
about any gaps in documentation that may represent an insufficiently documented diagnosis
, What has been called the equalizer for prospective inpatient reimbursement? - verified answer
Severity-based DRG
What is the ultimate goal of the installation of the POA indicator? - verified answer To consider
severity, resource utilization, and quality indicators in reimbursement
Within how many hours of discharge does the attending physician normally provide the discharge
summary to the coding department? - verified answer 24-48
Which form of documentation is the essence of the health record on which the coder relies? -
verified answer Progress notes
A query is necessary when a conflict in documentation exists between an attending physician and
which practitioner? - verified answer Anesthesiologist
What does the fifth digit "1" represent with regard to the myocardial infarction code? - verified
answer Current admission
What is suggested as a requirement for reflection of current medical practices and supports
worldwide epidemiology? - verified answer New coding system
A 3M study suggested that the reimbursement impact on the implementation of ICD-10-CM/PCS
would be what? - verified answer Minimal
What is the estimated negative impact of the top 25 MS-DRGs mentioned in the text? - verified
answer 1.4 percent
What is the first step required to determine the facility specific impact of ICD-10 implementation? -
verified answer Begin dual coding
What is the principal tool used by CDI programs to enhance efficiency? - verified answer Analytics
What should the facilities interested in investing in a CDI program perform on data and
documentation? - verified answer Objective analysis
What is a reason a physician documentation can be difficult to review? - verified answer Illegible
handwriting
The best scientific data available for clinical documentation is also known as - verified answer
Evidence-based medicine
The two-part theory for high-quality clinical documentation is a cause-and-effect theory that is
derived from which two sources? - verified answer Legal/Regulatory Sources and Peer-Reviewed
Research
When discussing completeness in a health record, the physician has fully addressed all concerns, as
well as what other authentication? - verified answer Signature and date
Peer-reviewed academic literature states that this factor shows a relationship to quality of care as
well as support for concurrent CDI programs: - verified answer Documentation
What evidence supports the lack of high-quality clinical documentation in the medical field? -
verified answer CDI is not taught in medical school
Which item is not recommended by the HHS and the OIG for minimum compliance with clinical
documentation regulations? - verified answer Physicians should include vaccination records
What does "reliable" in high-quality clinical documentation mean? - verified answer Physician
documentation supports medical treatment
Which item is an important aspect of consistent high-quality clinical documentation? - verified
answer Creates a clear picture for subsequent reviewers of documentation
Which aspect of the discharge summary is the biggest challenge to house staff, mid-level
practitioners, and attending physicians as they compose the patient's discharge summary? - verified
answer Timeliness
,Which aspect of the patient's health record can a member of the house staff or midlevel practitioner
create, yet ultimately needs the attending physician to confirm accuracy? - verified answer Problem
list
Interns, residents, and fellows are physicians with lesser accountability due to their inability to act as
an attending physician and are also known as ______. - verified answer House staff
Which two medical professionals serve as mid-level practitioners by supporting physicians in the
delivery of care? - verified answer Nurse practitioners and physician assistants
In 1982, which aspect of medical billing/reimbursement increased the demand for accuracy and
timeliness with regard to medical coding? - verified answer Reimbursement was driven by codes
assigned to patient care
Which hands-on provider's documentation should the coder not use for final coding? - verified
answer Diagnostic radiologist
Which practitioners, along with coding professionals, are proficient at picking up deficiencies in
clinical documentation yet must focus on giving care? - verified answer Nurses
Which healthcare setting requires high levels of proactivity from management and clinical teams to
ensure accurate and timely clinical documentation? - verified answer Outpatient
Which item is not an inpatient healthcare setting? - verified answer Emergency department
High-quality clinical documentation is the basis for what standard? - verified answer Gold standard
What allows the diagnostic, treatment, and response of information of the patient to be aggregated
into a uniform data set? - verified answer Coding
What part of the health record, usually located at the end the document, provides a complete
picture of the patient's diagnosis? - verified answer Impression and plan
What description is an aspect of the coding professionals' job? - verified answer Asking the physician
about any gaps in documentation that may represent an insufficiently documented diagnosis
, What has been called the equalizer for prospective inpatient reimbursement? - verified answer
Severity-based DRG
What is the ultimate goal of the installation of the POA indicator? - verified answer To consider
severity, resource utilization, and quality indicators in reimbursement
Within how many hours of discharge does the attending physician normally provide the discharge
summary to the coding department? - verified answer 24-48
Which form of documentation is the essence of the health record on which the coder relies? -
verified answer Progress notes
A query is necessary when a conflict in documentation exists between an attending physician and
which practitioner? - verified answer Anesthesiologist
What does the fifth digit "1" represent with regard to the myocardial infarction code? - verified
answer Current admission
What is suggested as a requirement for reflection of current medical practices and supports
worldwide epidemiology? - verified answer New coding system
A 3M study suggested that the reimbursement impact on the implementation of ICD-10-CM/PCS
would be what? - verified answer Minimal
What is the estimated negative impact of the top 25 MS-DRGs mentioned in the text? - verified
answer 1.4 percent
What is the first step required to determine the facility specific impact of ICD-10 implementation? -
verified answer Begin dual coding
What is the principal tool used by CDI programs to enhance efficiency? - verified answer Analytics
What should the facilities interested in investing in a CDI program perform on data and
documentation? - verified answer Objective analysis
