CDI Exam Latest 2024 | CDI Actual Exam
Update Latest 2024 Questions and
Correct Answers Rated A+
What is a reason a physician documentation can be difficult to review?
-ANSWER-Illegible handwriting
The best scientific data available for clinical documentation is also
known as -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? -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? -
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: -ANSWER-Documentation
What evidence supports the lack of high-quality clinical documentation
in the medical field? -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? -ANSWER-
Physicians should include vaccination records
,What does "reliable" in high-quality clinical documentation mean? -
ANSWER-Physician documentation supports medical treatment
Which item is an important aspect of consistent high-quality clinical
documentation? -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? -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? -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 ______. -ANSWER-House staff
Which two medical professionals serve as mid-level practitioners by
supporting physicians in the delivery of care? -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? -
ANSWER-Reimbursement was driven by codes assigned to patient
care
Which hands-on provider's documentation should the coder not use
for final coding? -ANSWER-Diagnostic radiologist
,Which practitioners, along with coding professionals, are proficient at
picking up deficiencies in clinical documentation yet must focus on
giving care? -ANSWER-Nurses
Which healthcare setting requires high levels of proactivity from
management and clinical teams to ensure accurate and timely clinical
documentation? -ANSWER-Outpatient
Which item is not an inpatient healthcare setting? -ANSWER-
Emergency department
High-quality clinical documentation is the basis for what standard? -
ANSWER-Gold standard
What allows the diagnostic, treatment, and response of information of
the patient to be aggregated into a uniform data set? -ANSWER-
Coding
What part of the health record, usually located at the end the
document, provides a complete picture of the patient's diagnosis? -
ANSWER-Impression and plan
What description is an aspect of the coding professionals' job? -
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? -ANSWER-Severity-based DRG
What is the ultimate goal of the installation of the POA indicator? -
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? -
ANSWER-24-48
Which form of documentation is the essence of the health record on
which the coder relies? -ANSWER-Progress notes
A query is necessary when a conflict in documentation exists between
an attending physician and which practitioner? -ANSWER-
Anesthesiologist
What does the fifth digit "1" represent with regard to the myocardial
infarction code? -ANSWER-Current admission
What is suggested as a requirement for reflection of current medical
practices and supports worldwide epidemiology? -ANSWER-New
coding system
A 3M study suggested that the reimbursement impact on the
implementation of ICD-10-CM/PCS would be what? -ANSWER-
Minimal
What is the estimated negative impact of the top 25 MS-DRGs
mentioned in the text? -ANSWER-1.4 percent
What is the first step required to determine the facility specific impact
of ICD-10 implementation? -ANSWER-Begin dual coding
What is the principal tool used by CDI programs to enhance
efficiency? -ANSWER-Analytics
Update Latest 2024 Questions and
Correct Answers Rated A+
What is a reason a physician documentation can be difficult to review?
-ANSWER-Illegible handwriting
The best scientific data available for clinical documentation is also
known as -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? -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? -
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: -ANSWER-Documentation
What evidence supports the lack of high-quality clinical documentation
in the medical field? -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? -ANSWER-
Physicians should include vaccination records
,What does "reliable" in high-quality clinical documentation mean? -
ANSWER-Physician documentation supports medical treatment
Which item is an important aspect of consistent high-quality clinical
documentation? -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? -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? -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 ______. -ANSWER-House staff
Which two medical professionals serve as mid-level practitioners by
supporting physicians in the delivery of care? -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? -
ANSWER-Reimbursement was driven by codes assigned to patient
care
Which hands-on provider's documentation should the coder not use
for final coding? -ANSWER-Diagnostic radiologist
,Which practitioners, along with coding professionals, are proficient at
picking up deficiencies in clinical documentation yet must focus on
giving care? -ANSWER-Nurses
Which healthcare setting requires high levels of proactivity from
management and clinical teams to ensure accurate and timely clinical
documentation? -ANSWER-Outpatient
Which item is not an inpatient healthcare setting? -ANSWER-
Emergency department
High-quality clinical documentation is the basis for what standard? -
ANSWER-Gold standard
What allows the diagnostic, treatment, and response of information of
the patient to be aggregated into a uniform data set? -ANSWER-
Coding
What part of the health record, usually located at the end the
document, provides a complete picture of the patient's diagnosis? -
ANSWER-Impression and plan
What description is an aspect of the coding professionals' job? -
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? -ANSWER-Severity-based DRG
What is the ultimate goal of the installation of the POA indicator? -
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? -
ANSWER-24-48
Which form of documentation is the essence of the health record on
which the coder relies? -ANSWER-Progress notes
A query is necessary when a conflict in documentation exists between
an attending physician and which practitioner? -ANSWER-
Anesthesiologist
What does the fifth digit "1" represent with regard to the myocardial
infarction code? -ANSWER-Current admission
What is suggested as a requirement for reflection of current medical
practices and supports worldwide epidemiology? -ANSWER-New
coding system
A 3M study suggested that the reimbursement impact on the
implementation of ICD-10-CM/PCS would be what? -ANSWER-
Minimal
What is the estimated negative impact of the top 25 MS-DRGs
mentioned in the text? -ANSWER-1.4 percent
What is the first step required to determine the facility specific impact
of ICD-10 implementation? -ANSWER-Begin dual coding
What is the principal tool used by CDI programs to enhance
efficiency? -ANSWER-Analytics
