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CDIP Study Guide Exam Questions and
Answers 100% Pass
Patients with more medications or vascular lines, and longer lengths of stay, were significantly
more likely to have higher rates of documentation errors. T/F? - ANS True
When should a provider provide documentation for the best quality of documentation? -
ANS Right after caring for a patient
What type of health record documentation should be top priority when undertaking a CDI
program? - ANS Inpatient Acute Care Health Record Documentation
What are the key activities of a CDI program? (2) - ANS Concurrent review and concurrent
physician inquiry
What is a common function that has created a problem for data integrity of the health record
that healthcare organizations should establish compliance guidance and well thought-out
processes on? - ANS Copy and Paste
When should a medical history and physical examination be completed? - ANS - No more
than 30 days before or 24 hours after admission or registration
- Prior to surgery or procedure requiring anesthesia services
, ©THESTAR 2025 ALL RIGHTS RESERVED
In what timeframe should a final diagnosis of a health record and a discharge summary be
placed according to CMS conditions of participation? - ANS Within 30 days following
discharge
Who does OIG used to administer Medicare A and B as well as to process claims for services
rendered? - ANS Medicare Administrative Contractors (MACs)
What is important about ventilation in the medical record? - ANS The timeframe of
ventilation.
What is a common type of malnutrition that the OIG has identified as an over-used diagnosis
resulting in overpayment under the MS-DRG system? - ANS Kwashiorkor Malnutrition
Four standards used in EBM (Evidence Based Medicine) - ANS Design
Terminology
Performance
Procedural
7 Quality Clinical Documentation Criteria - ANS Legible
Reliable
Precise
Complete
Consistent
Clear
Timely
Make sure to be able to identify examples of these*
, ©THESTAR 2025 ALL RIGHTS RESERVED
Each clinical criteria in a patient's health record must meet what? - ANS ALL seven of the
criteria (gold standard) for clinical documentation
What might be required if a discharge summary is inconsistent with other entries in the health
record? - ANS A query
What does the 2014 ICD-10-PCS guidelines state is essential to achieve complete and accurate
documentation? - ANS A joint effort between the healthcare provider and the coder
When there is provider disagreement on a diagnosis in the record or the diagnosis is unclear
coders must always? - ANS Submit a query to clarify
Which physicians documentation is used for coding if two providers cannot agree? - ANS The
attending physician's documentation
What all is required in an Emergency Department Record? - ANS The ED record must include
the time, means of arrival, immediate care and treatment notes, final disposition, condition at
discharge, and instructions for follow-up.
Often the physician copies the entire__________and pastes it into the discharge summary,
giving the appearance that all the diagnoses on the list are pertinent to the current admission. -
ANS Problem List
The purpose and scope of the problem list in all healthcare settings (inpatient, outpatient
facility, and physician practice) should: - ANS - Facilitate continuity of care between patient
visits
- Provide a comprehensive list of patient problems for use in patient care and secondary data
reporting
- Serve as a communication vehicle during transitions of care and between care providers
CDIP Study Guide Exam Questions and
Answers 100% Pass
Patients with more medications or vascular lines, and longer lengths of stay, were significantly
more likely to have higher rates of documentation errors. T/F? - ANS True
When should a provider provide documentation for the best quality of documentation? -
ANS Right after caring for a patient
What type of health record documentation should be top priority when undertaking a CDI
program? - ANS Inpatient Acute Care Health Record Documentation
What are the key activities of a CDI program? (2) - ANS Concurrent review and concurrent
physician inquiry
What is a common function that has created a problem for data integrity of the health record
that healthcare organizations should establish compliance guidance and well thought-out
processes on? - ANS Copy and Paste
When should a medical history and physical examination be completed? - ANS - No more
than 30 days before or 24 hours after admission or registration
- Prior to surgery or procedure requiring anesthesia services
, ©THESTAR 2025 ALL RIGHTS RESERVED
In what timeframe should a final diagnosis of a health record and a discharge summary be
placed according to CMS conditions of participation? - ANS Within 30 days following
discharge
Who does OIG used to administer Medicare A and B as well as to process claims for services
rendered? - ANS Medicare Administrative Contractors (MACs)
What is important about ventilation in the medical record? - ANS The timeframe of
ventilation.
What is a common type of malnutrition that the OIG has identified as an over-used diagnosis
resulting in overpayment under the MS-DRG system? - ANS Kwashiorkor Malnutrition
Four standards used in EBM (Evidence Based Medicine) - ANS Design
Terminology
Performance
Procedural
7 Quality Clinical Documentation Criteria - ANS Legible
Reliable
Precise
Complete
Consistent
Clear
Timely
Make sure to be able to identify examples of these*
, ©THESTAR 2025 ALL RIGHTS RESERVED
Each clinical criteria in a patient's health record must meet what? - ANS ALL seven of the
criteria (gold standard) for clinical documentation
What might be required if a discharge summary is inconsistent with other entries in the health
record? - ANS A query
What does the 2014 ICD-10-PCS guidelines state is essential to achieve complete and accurate
documentation? - ANS A joint effort between the healthcare provider and the coder
When there is provider disagreement on a diagnosis in the record or the diagnosis is unclear
coders must always? - ANS Submit a query to clarify
Which physicians documentation is used for coding if two providers cannot agree? - ANS The
attending physician's documentation
What all is required in an Emergency Department Record? - ANS The ED record must include
the time, means of arrival, immediate care and treatment notes, final disposition, condition at
discharge, and instructions for follow-up.
Often the physician copies the entire__________and pastes it into the discharge summary,
giving the appearance that all the diagnoses on the list are pertinent to the current admission. -
ANS Problem List
The purpose and scope of the problem list in all healthcare settings (inpatient, outpatient
facility, and physician practice) should: - ANS - Facilitate continuity of care between patient
visits
- Provide a comprehensive list of patient problems for use in patient care and secondary data
reporting
- Serve as a communication vehicle during transitions of care and between care providers
