SUNY Downstate Medical Center | MBCE 4010 | Clinical Documentation Improvement (CDI) All Chapters Quizzes Answered 2025/26.

SUNY Downstate Medical Center | MBCE 4010 | Clinical Documentation Improvement (CDI) All Chapters Quizzes Answered 2025/26. Chapter 1 1. Which of the following is a reason physician documentation can be difficult to review? A. High volume of pages B. Illegible handwriting C. Typographical errors D. Deficiencies 2. The best scientific data available for clinical documentation is also known as A. Evidence-Based Medicine B. Medical Necessity C. Best-of-Practice D. Gold Standard 3. The two-part theory for high-quality clinical documentation is a cause-and-effect theory that is derived from which two sources? A. Legal/Regulatory Sources and Peer-Reviewed Research B. American Health Information Management Association and the Joint Commission C. Centers for Medicare/Medicaid Services (CMS) and the Department of Health and Human Services (HHS) D. OIG and CMS 4. When discussing completeness in a health record, the physician has fully addressed all concerns, as well as what other authentication? A. Signature and date B. Nurses signature and date C. Initials and date D. Signature Stamp 5. Peer-reviewed academic literature states that this factor shows a relationship to quality of care as well as support for concurrent CDI programs: A. Facility Type B. Validity C. Documentation D. Medical Necessity 6. What evidence supports the lack of high-quality clinical documentation in the medical field? A. CDI is a high priority for healthcare organizations B. Reading and collecting data is a prevalent and consistent process C. Outpatient documentation is too complex D. CDI is not taught in medical school7. Which item below is not recommended by the HHS and the OIG for minimum compliance with clinical documentation regulations? A. Physicians should include vaccination records B. Progress, response, and changes are to be documented C. Health record should be completely legible D. Past and present diagnosis should be easily accessible 8. Which item below is not one of the seven criteria for high-quality documentation? A. Reliable B. Concise C. Complete D. Consistent 9. What does “reliable” in high-quality clinical documentation mean? A. Physician documentation supports past encounters B. Physician documentation supports medical necessity C. Physician documentation supports upcoming visits D. Physician documentation supports medical treatment 10. Which item below is an important aspect of consistent high-quality clinical documentation? A. Nurses’ progress notes are separated from physician notes B. Creates a clear picture for subsequent reviewers of documentation C. Contradictions occur within subsequent progress notes D. Laboratory findings are populated in a grid layoutChapter 2 1. 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? A. Accuracy B. Consistency C. Clarity D. Timeliness 2. 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? A. Progress notes B. History and physical C. Problem list D. Physicians orders 3. Interns, residents, and fellows are physicians with lesser accountability due to their inability to act as an attending physician and are also known as ______. A. House staff B. Diagnosticians C. Consultants D. Physician executives 4. Which two medical professionals serve as mid-level practitioners by supporting physicians in the delivery of care? A. Consultants and therapists B. Physician assistants and nurses C. Nutritionists and diagnosticians D. Nurse practitioners and physician assistants 5. In 1982, which aspect of medical billing/reimbursement increased the demand for accuracy and timeliness with regard to medical coding? A. Reimbursement was driven by codes assigned to patient care B. Medical necessity and best-of-practice C. Health Information Portability and Accountability Act (HIPAA) D. Joint Commission and other accreditation organizations installing clinical documentation guidelines6. Which of the following hands-on provider’s documentation should the coder not use for final coding? A. Attending physician B. Surgeon C. Diagnostic radiologist D. Interventional cardiologist 7. Which practitioners, along with coding professionals, are proficient at picking up deficiencies in clinical documentation yet must focus on giving care? A. Mid-level practitioners B. Nurses C. Surgeons D. Consultants 8. Which healthcare setting requires high levels of proactivity from management and clinical teams to ensure accurate and timely clinical documentation? A. Physical therapy B. Emergency department C. Inpatient D. Outpatient 9. Which of the below items is not an inpatient healthcare setting? Emergency department A. Rehabilitation facilities B. Skilled Nursing facilities C. Sub Acute facilities 10. High-quality clinical documentation is the basis for what standard? A. The Joint Commission B. Clinical documentation improvement standard C. Gold standard D. AHIMA regulatory standardChapter 3 1. What allows the diagnostic, treatment, and response of information of the patient to be aggregated into a uniform data set? A. Physician documentation B. Transcription C. Coding D. Clinical documentation improvement 2. What part of the health record, usually located at the end the document, provides a complete picture of the patient’s diagnosis? A. History and physical B. Consultation reports C. Assessment and exam D. Impression and plan 3. Which description below is an aspect of the coding professionals’ job? A. Analyzing the diagnostic codes previously listed during other episodes of care and correcting any errors B. Deciphering lab values and radiology reports for clinical diagnosis C. Asking the physician about any gaps in documentation that may represent an insufficiently documented diagnosis D. Reviewing the case mix index for errors to increase reimbursement 4. What has been called the equalizer for prospective inpatient reimbursement? A. Severity-based DRG B. ICD-10-CM C. Current Procedural Terminology D. POA indicators 5. What is the ultimate goal of the installation of the POA indicator? A. To provide the revenue cycle with additional variables to measure cost B. Aiding the physicians while deciphering the treatment timeline C. To consider severity, resource utilization, and quality indicators in reimbursement D. Providing additional variables to CMS for statistical purposes 6. Within how many hours of discharge does the attending physician normally provide the discharge summary to the coding department? A. 6–12 B. 24–48 C. 12–24 D. 48–727. Which form of documentation is the essence of the health record on which the coder relies? A. Consultation report B. Operative report C. Progress notes D. Discharge summary 8. Which of these organizations is not one of the four cooperating parties of ICD-9-CM? A. JCAHO B. AHIMA C. CMS D. AHA 9. A query is necessary when a conflict in documentation exists between an attending physician and which practitioner? A. Nurse B. Diagnostic Radiologist C. Pathologist D. Anesthesiologist 10. What does the fifth digit “1” represent with regard to the myocardial infarction code? A. Subsequent admission B. Current admission C. Anterolateral wall D. True Posterior wallChapter 4 1. All of the following are deficiencies in ICD-9-CM related to new advances in medicine, except: A. Measurement of healthcare services B. Quality measurement C. Use of clinical indicators D. Tracking of public health issues 2. All of the following are key deficiencies related to reimbursement posed by ICD-9-CM, except: A. Exactness B. Coding conventions C. Quality D. Flexibility 3. What is suggested as a requirement for reflection of current medical practices and supports worldwide epidemiology? A. Advanced quality measures B. Enhanced healthcare services C. Increased tracking of health issues D. New coding system 4. Which item below is not an improvement found in ICD-10-CM? A. Influenza B. Obstetrics C. Diabetes D. Laterality 5. A 3M study suggested that the reimbursement impact on the implementation of ICD-10- CM/PCS would be what? A. Agonizing B. Minimal C. Extensive D. Extraordinary 6. What is the estimated negative impact of the top 25 MS-DRGs mentioned in the text? A. 0.05 percent B. 0.85 percent C. 1.4 percent D. 2.6 percent7. What is the first step required to determine the facility specific impact of ICD-10 implementation? A. Create analytic report formats B. Determine root cause of MS-DRG change C. Contact the IT department to determine which analytic reports are currently available D. Begin dual coding 8. What is the principal tool used by CDI programs to enhance efficiency? A. Quality measures B. Analytics C. Risk mitigation D. Health issues tracking 9. All of the items below are reasons that trends are measured except: A. Developing corrective action plan B. Implementing stakeholder education programs C. Department operational budgets D. Establishing high risk/volume focus 10. All of these items below are steps for estimating the impact on reimbursement by ICD-10- CM/PCS on your facility, except: A. Determine the IPPS hospital-specific base rate B. Identify annual case volume and weight for MS-DRGs C. Compare payments to determine potential loss for each MS-DRG D. Compile a Word document summarizing all analyticsChapter 5 1. What should the facilities interested in investing in a CDI program perform on data and documentation? A. Quality analysis B. Objective analysis C. Internal audit analysis D. Revenue cycle analysis 2. When analyzing coding data, what system has one of the highest levels of aggregation? A. POA B. APC C. CMI D. DRG 3. Which reimbursement method allows for multiple assignments for each encounter and allows for the analysis of clinical documentation to remain on the coding level? A. POA indicators B. APC C. CPT-4 D. MS-DRG 4. During the review of clinical documentation, on what is it imperative to focus the review? A. Current provider documentation B. Vital sign flowsheets C. Problem lists D. POA indicators 5. Review of inconsistencies or patterns that do not meet DRG target norms, allows this data to be used for what purpose? A. Quality improvement process B. Internal physician audits C. Revenue cycle analysis D. Clinical documentation Assessment 6. What are the two types of data the review team should consider in the CDI analysis process? A. Patient severity; Length of stay data B. Number of errors in consultation reports; delinquency rates by providers C. Data produced by the organization; data produced by others about the organization D. Number of CCs and MCCs; CMI discrepancies 7. Most organizations review data on a regular basis by ______, as part of _______ analysis? A. Service type; regulatory B. Diagnostic-Related Group; Case mix C. Auditing; Case mix index D. Specialty; revenue cycle8. Changes in these two rates may suggest problems with clinical documentation? A. Major complication or comorbidity and complication or comorbidity B. DRG; Case mix C. Primary and secondary diagnostics D. Level of severity; Medicare quality indicators 9. Which type of review takes place while the patient is still in the hospital and when the patient leaves the hospitals? A. Initial; Subsequent B. Primary; Secondary C. Pre-Billing; Post-Billing D. Concurrent; Retrospective 10. The ____________ is one of the key indicators used to monitor a successful CDI program. A. APC B. CDI review C. Capture rate D. Retrospective reviewChapter 6 1. What is one important reason for having a CDI vision statement? A. Vision statements are usually part of the administrative operating policy B. It provides a purpose for the program C. It provides justification for the investment in CDI D. The Joint Commission requires it for certification 2. Prior to creating a vision statement for clinical documentation and CDI, what is the first necessary step? A. Hold an HIM interdepartmental meeting for suggestions B. Invite discussion by essential leaders in areas that might impact CDI process C. Let the leading physicians and hospital directors design a rough draft D. Browse the Internet for peer recommendations and suggestions 3. Which committee should be comprised of executive management, a physician advisor, a leader for clinical documentation and CDI, and the manager of a CDI program? A. Operational B. Executive leadership C. Clinical documentation improvement D. Oversight 4. What committee is comprised of individuals responsible for day-to-day management and support for the CDI program? A. Executive leadership B. Oversight C. Clinical documentation improvement D. Operational 5. What is the most essential role the oversight committee plays? A. Supervise the design of follow-up training for physicians B. Obtain and maintain support from the medical staff C. Oversee training of physicians and other clinicians D. Obtain contract resources to support day-to-day needs 6. Which hospital leader should provide the initial announcement for the CDI program the organization installs? A. Director of HIM B. Chief information officer C. Chief medical officer D. Chief executive officer 7. When refreshing an existing CDI program, what is one of the recommendations when quality or mortality scores decline? A. Case audit to determine if it is a coding or clinical documentation issue B. Analytics to determine focused DRGs impact C. Request operational oversight committee re-evaluate data D. Review major complications or comorbidities compared to peer data8. What is one of the key concepts in communication regarding CDI the organization should consider? A. High-quality graphics B. The cost of the communication C. What media the organization will use to communicate it D. Use of word of mouth 9. What is the key to success and sustainability of the CDI program? A. Physician support B. Quality vision statement C. Executive communication D. Clinical documentation improvement 10. The operational committee is responsible for which process on an ongoing basis? A. Communication with medical staff B. Queries for high-quality clinical documentation C. Revising the vision statement D. Analyzing metrics for program successChapter 7 1. Which executive must be involved in designing communication of the clinical documentation program from the start? A. Revenue cycle leader B. Health information director C. Clinical documentation consultant D. Physician executive 2. What must happen in order to obtain ultimate success with regard to clinical documentation? A. Give proper attention has to the mission statement B. Align physician leaders with executive management structure C. Adopt a program structure that fits the organization D. Dotted-line organization between physician leaders and CDI leaders 3. The advent of the EHR has increased the amount of documentation based largely due to: A. CDI B. Joint Commission requirements C. Ease of entry D. Reporting 4. What is the minimum recommended length of training in clinical documentation for the CDI physician leader? A. 3 to 6 months B. 1 to 3 months C. 100 hours D. 40 hours 5. When the CDI program encounters a problematic physician, who should control and resolve the situation? A. Physician leader for CDI B. VP of revenue cycle C. Medical staff leader D. Informal peer CDI leader 6. Who must be a creative and out-of-the box thinker in order for the CDI program to be a success? A. Director of HIM department B. Director of CDI department C. Director of physician leadership D. Director of executive management 7. The CDI specialist is required to handle which day-to-day activities: A. Track program costs and savings B. Direct the flow of the CDI program as it evolves C. Resolve any problems with problematic physicians D. Training staff, physicians, and health record review8. Who should be an effective physician communicator, and excellent at reading clinical documentation and data to uncover low-quality clinical documentation? A. Clinical documentation director B. Physician leader C. Clinical documentation improvement practitioner D. Physician executive 9. A goal of every CDI program is to obtain high-quality clinical documentation _________. A. Before the CDI team finishes installing the CDI program B. Prior to the patient being discharged from the hospital C. Before recovery audit contractors discover inaccuracies and deficiencies D. Before the revenue cycle auditors discover deficiencies 10. An effective CDI program should be able to capture 70 to 75 percent of the query responses _______. A. Concurrently B. Retrospectively C. Consecutively D. SimultaneouslyChapter 8 1. What theory does the scientifically validated CAMP method for clinical documentation training draw upon? A. The gold standard of CDI B. Adult learning theory of self-efficacy C. Quality improvement theory D. Health information theory 2. What is the keystone to every CDI program? A. Coder staff training B. Installing a cost effective CDI program C. Physician training D. Creating a vision that demonstrates the goals of the organization 3. Which of these is vital to moving forward with a comprehensive physician-training program? A. Locating the appropriate outside resources B. Leading coder staff in physician-training sessions C. Peer leader training D. Executive team and physician leader support 4. Research based on the scientific method is used to demonstrate value to whom? A. Executive team B. CDI team C. Physicians D. Clinical scientific support staff 5. Which member of the CDI training team is essential for optimal training outcomes? A. Chief medical officer B. Chief information officer C. Director of CDI department D. Peer physician 6. Which CDI trainer should be well versed in clinical documentation principles, quality indicators, and coding and reimbursement methodologies? A. Physician trainer B. Nonphysician trainer C. Leader executive team D. Oversight committee leader 7. Which type of physician is often top priority for CDI training and account for, on average, 60 percent of the hospital admissions? A. Hospitalist B. Cardiologist C. Endocrinologist D. Orthopedic surgeon8. In the CAMP acronym, what does the M stand for? A. Medicine B. Mentoring C. Mastering D. Methodology 9. In the CAMP acronym, asking means: A. Questions students ask that the trainer needs to address B. Asking for feedback from physician students at the right time C. Asking coders which are the appropriate codes to use D. Querying, focusing on concurrent queries 10. A typical CAMP training program consists of: A. Weeks of hands-on mentoring of CDI leadership B. Interactive online training and materials for everyone C. Heavy coding-specific training for hospitalists D. Four hours of training for physicians to learn core conceptsChapter 9 1. The CDI staff training is recommended to be a three-part program. Which is one of the three parts? A. Advanced ICD-9 and ICD-10 coding process B. Psychology of team dynamics C. Program data collection and analysis D. Advanced use of the EHR 2. What should be done after the entire training program is complete for CDI staff? A. Testing and self-evaluation B. Begin training on Medicare Quality Indicators C. Recognition by program executives D. Training for ICD-10 CM 3. Clinical documentation determines actual and perceived quality of care which makes it important to train CDI staff on what basics of Medicare? A. Best-of-practice B. Quality indicators C. Medical necessity D. Present on admission 4. The health record review process and what other aspect allow for the highest level of quality in clinical documentation? A. Training on the revenue cycle B. Medical necessity C. Training on basics of coding D. Physician queries 5. What should the CDI program staff do after the majority of classroom basics have been discussed? A. Shadow the revenue cycle team B. Partner with leading medical staff members C. Case review on the nursing units D. Independently review and analyze multiple types of records 6. The CDI specialists are partnered with the CDI trainees to discuss which aspect of the record review process? A. Present on admission B. Medical necessity C. Medicare claims D. Sources of query opportunities 7. Which tool is used by the CDI program staff to generate reports using entered data elements? A. LOS metrics B. CDI Monitor C. Encoder D. Grouper8. What can the CDI program staff generate by training the documenting clinicians on the CDI basics? A. Medical necessity requirements B. Retrospective patient satisfaction reports C. Clinically valid queries D. Revenue cycle reports 9. Which of these below should be given high priority CDI training due to their partnership with physicians? A. Nurses practitioners B. Respiratory therapists C. Phlebotomist D. Physical therapists 10. It is vital to provide CDI training to anyone who performs _______. A. Collection of lab specimens B. Charting of vital signs C. Documentation in clinical records D. Analysis of the revenue cycleChapter 10 1. There is currently no benchmark for this metric; each organization should determine it: A. Length of stay B. CC capture rate C. Physician response rate D. Retrospective query response rate 2. Which is a primary reason for the demand for high-quality clinical documentation? A. Quality control B. Code assignment C. Medicare medical necessity D. Physician time demand 3. Clinical documentation policies and procedures should: A. Dictate the practices and procedures for medical treatment B. Encompass nationally recognized guidelines C. Meet all the requirements of physician leaders D. Be created by and specifically for each organization 4. Though the goal for concurrent documentation review should be 100 percent, which type of inpatient stay makes it hard for any meaningful review? A. One-day stays B. Medicare or Medicaid C. Same-day surgery D. Newborn or maternal 5. Establishing the __________ rate is determined through the assessment process and could take several months. A. Physician query B. Query response C. Target review D. Deficiency 6. If the agreement rate on retrospective queries for a physician is 100 percent, this could be a sign of: A. A lack of responsiveness B. Leading queries C. Cooperation D. Exceptionally well-written queries 7. With continued querying and follow-up training, what is the expected result? A. Query rate reduction B. Query rate increase C. Increased manpower needs D. Improved MCC capture rates8. What has been proven to produce higher levels of patient quality of care? A. Increase target review rate B. Updated physician query process C. Educating leading physician in query process D. Concurrent clinical documentation 9. The CDI staff should perform concurrent record review on the ______ day of admission. A. First B. Second C. Third D. Final 10. Why should CDI staff be teamed up with a coding professional? A. To improve team morale B. To increase the number of CDI audits C. To speed up the concurrent review D. To achieve CDI organizational goalsChapter 11 1. What should be organization-specific with regard to key metrics? A. Validation review levels B. Query rates C. Metric targets D. Record review rate 2. It is important to report and analyze CDI key metrics in what form? A. Individual B. Aggregate C. Distributive D. Statistical 3. What should individual rates that are different from the target rates be? A. Ignored as outliers B. Reported to medical staff C. Stored for later use D. Investigated for significance 4. The purpose of ______________ is to identify any gaps in knowledge or skills for appropriate corrective action. A. Revenue cycle analysis B. Compiling and analyzing key metrics C. Physician query training D. Clinical documentation improvement 5. Hospitals often track the physician response rate. What could a level lower than benchmark reflect? A. Charts are illegible B. Too many queries C. Principle diagnosis change D. Lack of physician-hospital alignment 6. In general, hospitals have higher quality scores when _____________. A. The majority of patients are severity level 2 or lower B. The majority of patients are severity level 1 C. The majority of patients are grouped in the higher severity levels D. Quality scores are consistent with patient satisfaction 7. Which of the following is the average DRG relative weight for inpatient cases and an indicator of average reimbursement per patient? A. Charge capture B. Case mix index C. DRG relative weight D. Real patient case mix8. What term below refers to the change in average reimbursement per patient that occurs when different types of patients are being admitted as compared to another period of time? A. Relative weight change B. CDI case mix change C. Capture rate change D. Real patient mix change 9. Which of the following occurs when a change in CMI occurs due to changes in documentation practice? A. CDI case mix change B. Real patient mix change C. Relative weight change D. Physician CDI change 10. Higher quality clinical documentation is a primary contributor to a higher level of __________. A. Physician query rate B. Physician response rate C. Severity level accuracy D. Case mix indexChapter 12 1. Which is an important component of follow-up education? A. Review of key metrics B. DTM (Direct teaching method) C. Compliance officer attendance D. Testing 2. A convenience sampling methodology implies: A. Selecting every fifth case by discharge date B. Selecting cases that are convenient to retrieve C. Selecting 30 cases randomly from discharges the same month D. Selecting one in five cases for each physician 3. What type of testing is best taken post-training? A. Multiple choice B. Verbal C. Fill-in the blank D. Pass-fail 4. What is one key component of a compliant CDI program? A. Detailed review of Joint Commission findings B. Documented, mandatory physician education C. Revenue cycle team involvement D. Exceeding query response targets 5. Detailed query documentation can be used to: A. Protect the hospital from law suits B. Protect the hospital against claims from physicians about leading queries C. Show the effects of follow-up training D. Protect the auditor from corrective action 6. A comprehensive retrospective review should be conducted at least once a year of what aspect of the CDI program? A. Proficiency statistics B. Compliance issues C. All query opportunities D. Core key measures 7. Qualified individuals who are not involved in the day-to-day operations of the CDI program should conduct a____________? A. Retrospective record audit B. Quality improvement review C. Key metric review D. Retrospective query process8. Which plan should be devised to respond to issues arising from the CDI compliance and operational audit process? A. CDI response plan B. Quality assurance plan C. CDI plan D. Corrective action plan 9. What is the goal of the CDI compliance review? A. To ensure adequate CDI improvement B. Compliant query generation and physician responses C. To ensure corrective action for any compliance concerns D. To ensure compliance between CDI program staff 10. When conducting an audit review of records for CDI, what would the minimum number of records to pull be? A. 10 percent B. 150 C. 30 D. 1 percent of retrospective reviewsChapter 13 1. Generally, initial CDI implementation programs should: A. Conduct reviews for all payers B. Plan expansion in small steps C. Be expanded in large steps D. Focus on patient satisfaction 2. Why is it important to obtain support of the medical staff when creating a physician report card? A. They will have to provide all the inputs B. There could be compliance issues C. It may impact their quality-of-care metrics D. It could harm hospital-physician relationships 3. The initial focus of a CDI implementation program in one patient care setting is often due to what reason? A. Profit is often focused in one area B. Implementation is must faster C. Targeting one area is less risky D. Investment measurement becomes more difficult 4. Treating these people as customers often develops a positive ongoing relationship with CDI staff. A. Patients B. Executive staff C. Coding and billing staff D. Medical staff 5. What is considered common ground between medical staff and the hospital? A. Healthcare reimbursement B. Health record C. Physician query process D. Clinical documentation improvement 6. When developing CDI training for physicians, you should: A. Position CDI as value-added B. Train emergency department staff first C. Develop a patient satisfaction survey D. Create physician report cards 7. What activity might create an environment ripe for continuous program renewal? A. Physician report cards B. Medical staff dissatisfaction C. Evolution of quality initiatives D. Lower staff turnover8. A benefit to the CDI program comes with the reporting of what phenomenon? A. Severity-of-illness outcomes B. CDI interfaces with other functions C. CDI program improvement D. Physician disapproval 9. What information should be collected as a measure of physician satisfaction? A. Metrics on professional fee reimbursement B. Attitudes and opinions on documentation practices C. Physician score cards D. Peer review 10. What should the CDI program be adding after the first year of implementation? A. Outpatient treatment areas B. Subtle refinements C. Community health education D. Comprehensive key measuresChapter 14 1. Which of the following is one of the four criteria describing the basics of best of practice CDI programs? A. Intangible best practices in middle revenue cycle B. Practices must be central to only one area C. Must be supported by research and actual application by multiple healthcare systems D. Best practices with high validity are included 2. When a meaningful ____________ is developed, an organization is more likely to achieve its goals and be profitable. A. Physician education B. Organizational value statement C. Vision statement D. CDI mission statement 3. Which item below is one of the three management areas that a best practice must affect? A. Medical staff B. Human resources C. Strategy D. Medical necessity 4. The CDI program must keep high-quality records of the query process for A. Revenue cycle analysis B. Compliance issues C. Chart deficiency tracking D. Reducing the workload on HIM 5. Which of the following groups are included in the feedback loop between denials, management, and CDI program staff? A. Compliance B. OIG C. CMS D. Payers 6. The CDI staff might create a feedback loop with which department to prevent disgruntled physicians from filing claims against them? A. Billing or finance B. Health information management C. Compliance D. Case management7. CDI staff members must work directly with this department to obtain data about retrospective physician queries. A. Coding B. Health information management C. Compliance D. Case management 8. Organizations that design their systems around this have been proven to be more successful. A. Physician queries B. Compliance C. Patients D. Utilization review 9. Which of the following is one of the five best practices for management of financial measures in the CDI program? A. Track and report on CC capture rates across the organization and by service B. Build relationships with QIO and primary insurers C. Publish data to benchmarking organizations D. Document corrective actions 10. A future goal for any CDI program should be to implement: A. A train-the-trainer program B. Real case mix index C. Relationship management with patients D. Six SigmaChapter 15 1. What stage of EHR transformation does the SEHR system benchmark with a mixture of discreet data, document imaging, and medical imaging? A. Stage 2 B. Stage 6 C. Stage 7 D. Stage 3 2. This stage shows the strongest correlation between higher quality indicators and the hospitals EHR scores: A. Stage 6 B. Stage 4 C. Stage 5 D. Stage 2 3. Which stage are vital signs and flow sheets required as electronic documentation? A. Stage 6 B. Stage 7 C. Stage 2 D. Stage 3 4. What is one of the key benefits of a Stage 7 transformation? A. Makes health information available to the patient B. Reduces implementation cost C. Fulfills compliance requirements with the Joint Commission D. Reduces HIPAA risks 5. What is the earliest stage in which the HCO fully implements the closed-loop medication administration environment in at least one patient care area? A. Stage 5 B. Stage 4 C. Stage 6 D. Stage 3 6. Which of the following is one of the five rights of medication administration? A. Place B. Privacy C. Provider D. Time 7. What stage of transformation does full closed-loop medication administration implementation in at least one patient care area represent? A. Stage 3 B. Stage 4 C. Stage 5 D. Stage 28. Stage 6 transformation includes implementing full physician documentation and what other item in at least one patient care area of the hospital? A. ICEHR B. Charting using structured templates C. RFID D. CDR 9. What median stage have most acute care facilities reached? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 10. Why is it essential for members of the compliance team to be involved in the entire EHR implementation process? A. To ensure HIPAA compliance B. Evolving regulatory guidelines C. To monitor cut and paste documentation D. Reimbursement riskChapter 16 1. CDI teams can use the time saved by using NLP applications to: A. Expand the program to include other payers B. Improve core measure indicators C. Decrease length of stay through discharge planning D. Identify insufficient provider documentation retrospectively 2. The first phase in the history of NLP is known for which technology? A. Artificial intelligence B. Grammatico-logical C. Machine translation D. Statistical language processing 3. Which technology provides mined information from a narrative content that combines with structured EHR data to identify deficiencies in clinical documentation? A. Machine learning algorithms B. Natural language understanding C. Real-time deficiency tracking D. Speech-understanding technology 4. Collaborative intelligence offers solutions for improving clinical documentation such as: A. Manual data abstraction B. Handwritten provider documentation scanning C. Direct provider communication D. Real-time documentation improvement 5. Built-in EHR prompts such as “type and acuity” of CHF are an example of using____________ to improve the clinical record. A. Revenue cycle acceleration B. Structured data elements C. Alternate patient scenarios D. Provider decision making 6. A content server captures data from a variety of sources in collaborative intelligence software, including: A. Patient registration B. Back-end billing C. Ancillary department CPT codes D. Concurrent review (CDIP) 7. Industry projections suggest ICD-10-CM/PCS will initially reduce productivity by _____ percent. A. 20 B. 30 C. 50 D. Yet to be determined8. Computer-assisted-coding applications can be paired with _____________software technology to increase MCC/CC capture rates. A. CDI B. CDM C. Inpatient code editor D. Semantic clinical reasoning 9. Typically two software modules are available to support the CDI program tasks including analytics and: A. Tracking B. Clinical evidence support C. Medical decision database D. Online coding editor 10. The concept search feature uses NLP to identify: A. Key words and phrases B. High-risk MS-DRGs C. Case mix index D. SOI/ROM levelsChapter 17 1. Why are MDTs formed by the CDI team leader? A. To improve clinical documentation B. To advance departmental interconnectivity C. To examine complex issues and develop solutions D. To develop revenue cycle integrity 2. Which item below is one of the goals of a CDI project? A. Provide revenue cycle history B. Determine average daily encounters C. Analyze inpatient departmental integrity D. Ensure accurate reimbursement 3. The departmental leadership team designated to oversee the CDI program includes: A. Emergency room techs B. Revenue integrity C. Billing department leads D. Case management staff 4. Which of the following performance improvements result from a cohesive core CDI team? A. Prevention of conflicting information communicated to the physicians B. Improvement of revenue cycle integrity C. Decrease in risk management claims D. Advancement in clinical technology 5. The establishment of _________ is an effective way to ensure that all members of the CDI program meet functional requirements for success. A. Departmental leadership B. Resident team C. Core team taskforce D. HIM leadership 6. The MDT approach provides a beneficial advantage of _____________. A. Advanced improvements in revenue recognition B. Increased versatility of core team C. Diverse schedules D. Increased exposure to different disciplines 7. Which member(s) of the medical staff is (are) usually assigned to the CDI program and reports directly to the medical staff leadership? A. HIM director B. Physician advisor C. Head nurse D. Departmental chiefs8. Which department of the hospital is responsible for providing the CDI team with CMI and DRG payment analytics? A. Medical staff leadership B. Care management C. Revenue integrity D. Quality management 9. The utilization review process gathers authorizations for continued stays and is provided by which department? A. Quality management B. Case management C. Revenue integrity D. Care management 10. What activity can help break down natural barriers and create a rich cooperative environment in which CDI thrives? A. Building team cohesiveness B. Direct reporting to taskforce C. Coordination of hospital charge master D. Assisting in post discharge planningChapter 18 1. Why do most organizations implement CDI in inpatient areas first? A. The HHS mandates it B. The amount of documentation per patient C. The greatest number of patients D. The lower cost of implementation 2. What is the fundamental difference in the CDI implementation process between inpatient and outpatient settings? A. Amount of documentation B. Examples used to teach physicians C. Use of retrospective review D. Physician level of expertise 3. Which of the following does documentation for services rendered, such as patient health records and physician orders, support? A. Best of practice B. Present on admission C. Medical necessity D. High-quality clinical documentation 4. Which of the following is a standardized methodology for the inpatient setting but not for the outpatient setting? A. Concurrent review B. Prospective review C. Consecutive review D. Retrospective review 5. What is an excellent tool for outpatient CDI training? A. Having residents learn ICD-10 coding B. Providing 10 case studies in the same training session C. Web-based training D. Having physicians shadow CDI specialists during audits 6. In the diagnostic laboratory setting, what is the challenge for physicians ordering tests prior to rendering services? A. Availability of patient record B. Accurate detailed documentation C. Complexity of cases D. Physician level of expertise 7. Outpatient CDI functions in the ED can be woven into which position’s duties? A. Receptionist B. Resident C. Case manager D. Department chief8. Which type of medical visit presents the highest level of volume? A. Office or clinical visits B. ED visits C. Ambulatory surgery visits D. Acute care visits 9. What is the primary reason for implementing a service-based CDI strategy? A. Patient appreciation B. Medicare funding C. Lower cost of implementation D. Quality of care 10. What aspect of CDI remains the same regardless of the practitioner or patient setting involved? A. Strategy B. Principles C. Training D. ProcessChapter 19 1. What can the CDI team do to improve communication with difficult staff members? A. Motivational speaking B. Case management strategies C. Critical analysis D. Critical thinking 2. The use of critical thinking allows for confidence through success, independent action, and which item below? A. Motivation B. Collaboration C. Communication D. Exploitation 3. Why is critical thinking necessary in the current healthcare setting? A. Determining CMI B. Increased DRG analysis C. Technological development D. Development in coding systems 4. Which item below increases complexity with the query process? A. Decreased face-to-face communication B. Increased nursing-unit exposure C. Increased guidelines D. Decreased networking capability 5. How have complex barriers burdened the query process? A. Decreased frequency B. Multi-network tracking C. Increased medical complexity D. Governing body guidelines 6. Workplace cultures that foster effective communication, collaboration, effective decisionmaking, appropriate staffing, meaningful recognition, and authentic leadership often have: A. Low productivity B. High turnover C. Less stress D. Leadership turnover 7. Problem-focused thinking can be helpful to: A. Extend the focus of “the problem” B. Assist in developing a solution C. Improve relationships D. Avoid the same problem in the future8. One major change found when moving to a newer EHR health information management systems is: A. Improved post discharge query follow up processes B. Lack of face-to-face communication C. Increased face time at the nursing stations D. Ease of communicating with the physician 9. Which causes a decrease in memory and other cognitive functions while causing the release of cortisol? A. Self control B. Critical thinking C. Decision making D. Stress 10. Effective critical thinking skills and improved interpersonal relationships will result in control of: A. Collaboration B. Emotion C. Work environment D. Decision making