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Question 1 reset

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A patient is admitted with pneumonia. The physician documents "pneumonia due to aspiration." The coding guidelines specify that the underlying condition should be sequenced first when the pneumonia is due to aspiration. Which diagnosis should be listed as the principal diagnosis?

Pneumonia

Aspiration

Respiratory failure

Sepsis

Question 2 reset

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During a retrospective CDI review, you identify a case where a patient with a history of chronic obstructive pulmonary disease (COPD) was admitted with acute exacerbation. The physician documentation only states "COPD exacerbation." What type of query would be most appropriate?

A yes/no query asking if the exacerbation was acute.

An open-ended query asking for clarification of the type of exacerbation.

A multiple-choice query offering options like acute exacerbation, chronic exacerbation, or acute-on-chronic exacerbation.

No query is needed as "exacerbation" implies acuity.

Question 3 reset

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A CDI specialist is reviewing a record and notes that a patient with diabetes mellitus developed a non-healing foot ulcer. The physician documents "diabetic foot ulcer." According to coding guidelines, what additional information should the CDI specialist look for in the documentation?

The type of diabetes (Type 1 or Type 2).

Whether the ulcer was present on admission.

The severity and depth of the ulcer.

The patient's HbA1c level.

Question 4 reset

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A new CDI specialist is unsure about querying a physician regarding the clinical significance of a low potassium level in a patient with heart failure who is on diuretics. What AHIMA practice brief would provide the BEST guidance on when to query for clinical significance?

Managing Queries in the Inpatient Setting.

Data Quality Management in Health Information Exchange.

Ethical and Documentation Practices for Clinical Documentation Improvement.

Understanding the Impact of Clinical Documentation on Quality Measures.

Question 5 reset

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The CDI department is developing a new policy for physician queries. Which of the following elements is ESSENTIAL to include in this policy based on AHIMA recommendations?

The number of queries initiated per physician per month.

The requirement for all queries to be closed within 24 hours.

The process for escalating unanswered queries through the chain of command.

The specific wording to be used in all query templates.

Question 6 reset

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A physician documents "septicemia." The CDI specialist reviews the record and finds no other documentation supporting a systemic infection, such as positive blood cultures or organ dysfunction. What type of query is MOST appropriate?

A clarification query asking for the specific organism.

A clinical validation query asking if the patient meets the criteria for septicemia.

A coding query asking for the ICD-10-CM code for septicemia.

No query is needed as "septicemia" is a documented diagnosis.

Question 7 reset

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The hospital is implementing a new electronic health record (EHR) with natural language processing (NLP) capabilities for CDI. What is a POTENTIAL risk associated with using NLP in CDI?

Increased physician query fatigue due to automated queries.

Improved accuracy in identifying documentation gaps.

Reduced workload for CDI specialists.

Real-time feedback to physicians on documentation.

Question 8 reset

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The CDI manager is presenting data on the impact of CDI efforts to the hospital administration. Which metric would BEST demonstrate the financial impact of improved documentation?

Total number of physician queries.

Average case mix index (CMI).

Number of documentation clarifications.

Physician query response rate.

Question 9 reset

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A CDI specialist identifies a discrepancy between the working DRG assigned by the encoder and the potential final DRG based on their review. What is the NEXT step the CDI specialist should take?

Immediately change the working DRG in the system.

Send a query to the physician for clarification.

Communicate the discrepancy to the coding department.

Document the discrepancy in the CDI tracking system and move on.

Question 10 reset

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During a CDI audit, it is noted that several queries lack clear and specific rationale for the documentation clarification being sought. This violates which AHIMA principle of ethical CDI practice?

Integrity and Transparency.

Confidentiality and Security.

Compliance and Accuracy.

Patient Advocacy.

Question 11 reset

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A patient is readmitted within 30 days for a condition that was present during the previous admission but not fully documented. The CDI specialist believes a post-discharge query is warranted. What is a key consideration for initiating a post-discharge query?

The physician's availability to respond.

The potential impact on quality measures and reimbursement.

The number of other outstanding queries for the same physician.

The patient's current health status.

Question 12 reset

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The CDI team is working with physician champions to improve documentation of hospital-acquired conditions (HACs). What is a key message to convey to the physicians?

Focusing on HAC documentation will decrease their workload.

Accurate HAC documentation reflects the quality of patient care.

Querying for HACs is primarily for reimbursement purposes.

HAC documentation is only important for government reporting.

Question 13 reset

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A CDI specialist is reviewing a record and notes that a patient with heart failure has documentation of "shortness of breath." To capture the severity of the heart failure, what additional documentation would be MOST helpful?

The patient's ejection fraction.

The medications the patient is taking at home.

The duration of the shortness of breath.

Whether the shortness of breath occurred at rest or with exertion.

Question 14 reset

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The hospital's CDI program is tracking the query response rate by individual physician. What is the PRIMARY purpose of tracking this metric?

To identify physicians who are not cooperating with CDI efforts.

To determine which physicians require additional education on documentation.

To assess the efficiency of the query process and physician engagement.

To compare physician performance for bonus incentives.

Question 15 reset

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A CDI specialist encounters a physician who consistently documents vague diagnoses without providing supporting clinical details. What is the BEST approach to address this pattern?

Send individual queries for every instance of vague documentation.

Escalate the issue to the physician's department chair.

Provide targeted education to the physician on the importance of specific documentation.

Ignore the pattern as long as the codes can still be assigned.

Question 16 reset

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A patient is admitted with acute kidney injury (AKI). The physician documents "AKI likely due to dehydration." What should the CDI specialist consider regarding the relationship between AKI and dehydration for coding purposes?

Dehydration is always the principal diagnosis when associated with AKI.

The documentation supports a definitive link, and AKI should be coded as due to dehydration.

Further clarification may be needed to confirm the causal relationship between dehydration and AKI.

AKI and dehydration should always be coded as co-existing conditions.

Question 17 reset

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The CDI department is asked to develop a dashboard of key performance indicators (KPIs). Which of the following would be a relevant KPI to include?

Number of CDI staff meetings held.

Percentage of records reviewed by the CDI team.

Average number of days between patient discharge and final coding.

Case mix index (CMI) change post-CDI review.

Question 18 reset

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A CDI specialist identifies a situation where a physician used a query template that included suggested diagnoses. This violates which ethical principle according to AHIMA?

Promoting retrospective documentation.

Leading the physician to a specific diagnosis.

Ensuring timely query responses.

Maintaining confidentiality of patient information.

Question 19 reset

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The hospital is undergoing an external audit, and the auditors are reviewing CDI query practices. What documentation should the CDI department be prepared to provide?

The personal contact information of the CDI staff.

A list of all physicians who received queries in the past year.

The hospital's CDI policy and procedures, including query templates and retention guidelines.

The individual performance evaluations of the CDI specialists.

Question 20 reset

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A patient with a history of heart failure is admitted with worsening dyspnea and fluid overload. The physician documents "acute decompensated heart failure." What key elements should the CDI specialist look for to ensure comprehensive documentation?

The patient's past medical history in detail.

The specific New York Heart Association (NYHA) functional class.

The patient's social history and lifestyle.

The results of routine laboratory tests.

Question 21 reset

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The CDI team is collaborating with the coding department on a project to improve the accuracy of Present on Admission (POA) indicator assignment. What is the PRIMARY goal of this collaboration?

To increase the hospital's reimbursement.

To ensure compliance with coding guidelines and accurate reporting of hospital-acquired conditions.

To reduce the number of physician queries related to POA.

To simplify the coding process.

Question 22 reset

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A CDI specialist is reviewing a record and identifies conflicting documentation regarding the presence of a pressure ulcer on admission. One note states it was present, while another suggests it developed in the hospital. What is the MOST appropriate action?

Assign the POA indicator as "Yes" based on the earliest documentation.

Assign the POA indicator as "No" assuming the later documentation is more accurate.

Query the physician for clarification regarding the POA status of the pressure ulcer.

Leave the POA indicator as "Unknown" due to the conflicting information.

Question 23 reset

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The CDI manager is developing an educational session for new residents on the importance of clinical documentation. What key message should be emphasized regarding the impact of their documentation?

It primarily affects the hospital's billing.

It is only reviewed by the coding department.

It impacts patient care, quality reporting, and reimbursement.

It is mainly used for legal purposes.

Question 24 reset

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A CDI specialist is reviewing a record for a patient with a urinary tract infection (UTI). The physician documents "UTI." What additional information would be beneficial to query for, if not already documented?

The patient's temperature.

The specific organism causing the infection.

The patient's white blood cell count.

The patient's history of UTIs.

Question 25 reset

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The CDI department is using a computer-assisted coding (CAC) system that flags potential documentation issues. What is a CRITICAL step in using CAC effectively?

Relying solely on the CAC system's suggestions for queries.

Validating the CAC system's flags with a thorough review of the medical record.

Automatically sending queries based on CAC system alerts.

Disregarding CAC system flags if the CDI specialist disagrees.

Question 26 reset

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A CDI specialist identifies documentation of "encephalopathy" in a patient with liver failure. To ensure accurate coding, what additional information is crucial to look for in the record?

The patient's Glasgow Coma Scale (GCS) score.

The specific type or cause of the encephalopathy (e.g., hepatic).

The patient's electrolyte levels.

The medications administered during the admission.

Question 27 reset

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The CDI team is asked to benchmark their query rate against other similar hospitals. What is a potential limitation of using query rate as the sole benchmark?

It doesn't reflect the complexity of the cases reviewed.

It is difficult to obtain comparable data from other hospitals.

It doesn't account for the experience level of the CDI staff.

It is not a recognized metric in the CDI field.

Question 28 reset

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A physician responds to a CDI query with additional documentation that is inconsistent with the original notes. What is the BEST course of action for the CDI specialist?

Accept the new documentation and update the record.

Disregard the new documentation as it contradicts the original record.

Initiate a second-level review to reconcile the conflicting information.

Query the physician again to clarify the inconsistency.

Question 29 reset

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The hospital's compliance officer is reviewing the CDI department's adherence to regulatory guidelines. What is a key area of focus for this review?

The number of charts reviewed by each CDI specialist.

The timeliness of physician query responses.

The appropriateness and clinical basis of physician queries.

The format and appearance of the query forms.

Question 30 reset

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A patient is admitted with chest pain. The initial EKG is normal, but serial troponins are elevated. The physician's final diagnosis is "non-ST elevation myocardial infarction (NSTEMI)." What documentation should the CDI specialist ensure is present to support this diagnosis?

A detailed family history of cardiac disease.

Documentation of the patient's risk factors for heart disease.

Clinical correlation of the elevated troponins with the patient's symptoms and other findings.

The patient's insurance information.

Question 31 reset

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The CDI team is developing a project to improve documentation of malnutrition. Which of the following would be a relevant data point to track as part of this project?

The number of dieticians consulted.

The percentage of patients with documented malnutrition who also have a low albumin level.

The average length of stay for patients with malnutrition.

The number of malnutrition-related queries sent to physicians.

Question 32 reset

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A CDI specialist encounters a query response from a physician that simply states "Agree" without providing any additional clinical details. What is the appropriate follow-up action?

Accept the response and close the query.

Send a follow-up query requesting specific clinical information.

Escalate the issue to the physician advisor.

Document the "Agree" response and move on.

Question 33 reset

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The hospital is implementing a new policy regarding the retention of CDI queries. According to best practices, how long should queries and physician responses typically be retained?

For the duration of the patient's admission.

For the same period as the medical record.

For one year after the patient's discharge.

For five years, regardless of the medical record retention policy.

Question 34 reset

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The CDI department is reviewing its query templates to ensure compliance. What is a KEY element to avoid in query wording?

Using abbreviations that are commonly understood by physicians.

Referencing specific clinical findings from the record.

Suggesting a specific diagnosis to the physician.

Clearly stating the documentation gap and the reason for the query.

Question 35 reset

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A CDI specialist is tracking the impact of CDI interventions on specific quality measures, such as the Hospital-Acquired Condition (HAC) reduction program. Which data point would be MOST relevant to monitor?

The total number of CDI reviews performed.

The change in the hospital's HAC rate after CDI initiatives.

The number of physician queries related to HACs.

The CDI team's satisfaction scores.

Question 36 reset

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A patient with a history of chronic kidney disease (CKD) is admitted with an elevated creatinine level. The physician documents "worsening CKD." What additional information should the CDI specialist look for to ensure accurate staging of CKD?

The patient's blood pressure readings.

The specific stage of CKD documented by the physician.

The patient's dietary restrictions.

The patient's medication list.

Question 37 reset

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The CDI manager is developing a training program for new CDI specialists. What topic related to compliance should be included?

How to access patient medical records securely.

The hospital's policy on employee dress code.

Ethical principles of CDI documentation and querying.

How to use the hospital's email system.

Question 38 reset

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A CDI specialist is reviewing a record and notes that a patient with pneumonia also has a pleural effusion. The physician only documents "pneumonia." What type of query would be appropriate?

A query asking if the pleural effusion is related to the pneumonia.

A query asking for the ICD-10-CM code for pleural effusion.

No query is needed as pneumonia often presents with pleural effusion.

A query asking about the size of the pleural effusion.

Question 39 reset

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The CDI department is utilizing natural language processing (NLP) to identify potential documentation gaps related to complications. What is a crucial step to ensure the accuracy of NLP-generated alerts?

Automatically generating queries for every NLP alert.

Implementing regular audits of NLP-identified cases by CDI specialists.

Allowing physicians to directly edit NLP-generated suggestions in the record.

Limiting CDI specialist review to only NLP-flagged cases.

Question 40 reset

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The CDI manager is presenting data on query outcomes to the medical staff. Which metric would BEST illustrate the value of CDI in improving documentation specificity?

The total number of queries sent.

The physician query response rate.

The percentage of queries that resulted in a change or addition to the documentation.

The average time it takes for physicians to respond to queries.

Question 41 reset

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A CDI specialist identifies a post-operative infection that was not documented as present on admission. What is the PRIMARY focus of the CDI specialist's review regarding this potential Hospital-Acquired Condition (HAC)?

To determine if the patient had any signs of infection prior to surgery.

To calculate the additional reimbursement the hospital might receive.

To ensure the infection is coded as a complication.

To assess the physician's documentation of the surgical procedure.

Question 42 reset

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The CDI team is collaborating with physician champions to improve documentation of acute vs. chronic conditions. What is a key strategy for this collaboration?

Sending mass emails to all physicians with documentation guidelines.

Holding individual meetings with physicians to review their documentation patterns and provide feedback.

Implementing mandatory online modules on documentation requirements.

Providing financial incentives to physicians with the lowest query rates.

Question 43 reset

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A patient with a history of heart failure and atrial fibrillation is admitted with worsening shortness of breath. The physician documents "heart failure exacerbation." What additional documentation would be helpful to capture the complexity of the patient's condition?

The patient's social support system.

The patient's anticoagulation status for atrial fibrillation.

The patient's past medical history in detail.

The patient's dietary preferences.

Question 44 reset

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The CDI department is asked to track the reasons for physician disagreement with CDI queries. What is the PRIMARY benefit of tracking this data?

To identify physicians who are resistant to CDI efforts.

To understand potential issues with query clarity or CDI specialist understanding.

To calculate the cost-effectiveness of the CDI program.

To justify the need for more CDI staff.

Question 45 reset

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A CDI specialist encounters a situation where the physician's query response is still unclear or does not adequately address the documentation gap. What is the NEXT appropriate step?

Accept the response and move on.

Send another query with more specific questions or examples.

Escalate the query to the physician advisor or a second-level reviewer.

Discuss the case with the coding department to determine the best coding based on the available documentation.

Question 46 reset

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The hospital's compliance plan includes regular audits of CDI activities. What is a key focus of these audits related to query practices?

The number of queries generated per CDI specialist.

The timeliness of query completion.

Adherence to ethical querying principles and avoidance of leading questions.

The length and format of the query forms.

Question 47 reset

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A patient is admitted with a stroke and develops aspiration pneumonia during their hospital stay. The physician documents both conditions. What should the CDI specialist consider when determining the Present on Admission (POA) indicator for the aspiration pneumonia?

Whether the stroke was present on admission.

The timing of the onset of the aspiration pneumonia relative to the admission date.

The severity of the aspiration pneumonia.

The treatment provided for the aspiration pneumonia.

Question 48 reset

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A CDI specialist is reviewing a record where a patient with morbid obesity is admitted for cellulitis. The physician documents "cellulitis due to obesity." According to coding guidelines, what is the appropriate sequencing of these conditions?

Cellulitis should be the principal diagnosis.

Obesity should be the principal diagnosis.

The condition that required the most treatment should be principal.

Either can be principal depending on the hospital's preference.

Question 49 reset

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The CDI department is asked to provide education to the medical staff on the importance of documenting the link between a symptom and a diagnosis (e.g., "cough due to pneumonia"). What is the PRIMARY reason for emphasizing this documentation practice?

It simplifies the coding process for the HIM department.

It provides a clearer clinical picture and supports accurate coding.

It increases the hospital's reimbursement potential.

It reduces the number of physician queries from the CDI team.

Question 50 reset

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A CDI specialist identifies a record where a patient with diabetes mellitus has documentation of "poorly controlled diabetes." What additional information would be MOST helpful to obtain for more specific coding?

The patient's current blood glucose level.

The type of diabetes (Type 1 or Type 2) and any associated complications.

The patient's family history of diabetes.

The patient's current medications for diabetes.

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