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AHIMA Certified Documentation Integrity Practitioner Sample Questions (Q89-Q94):

NEW QUESTION # 89
The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the

Answer: A

Explanation:
Explanation
The physician advisor/champion is a key role in the CDI program who serves as a liaison between the CDI staff and the organization's medical and surgical staff. The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the organization's medical and surgical staff to promote awareness, understanding, and compliance with CDI initiatives and goals.
References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 97-98.


NEW QUESTION # 90
Based on the flowchart below, at what point might the clinical documentation integrity practitioner (CDIP) enlist the help of the physician advisor/champion?

Answer: D


NEW QUESTION # 91
Creating policies and procedures for the query process will help eliminate

Answer: A

Explanation:
Explanation
Creating policies and procedures for the query process will help eliminate confusion among CDI staff, providers, coders, and other stakeholders regarding the purpose, scope, format, and expectations of the query process. Policies and procedures should be based on industry standards and best practices, and should be reviewed and updated regularly.
References: AHIMA/ACDIS. "Guidelines for Achieving a Compliant Query Practice (2019 Update)." Journal of AHIMA 90, no. 2 (February 2019): 20-29.


NEW QUESTION # 92
Which of the following is MOST likely to trigger a second-level review?

Answer: C

Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a second-level review is a process that involves a review of coded records by a designated person or team to ensure the accuracy and completeness of coding and documentation1. A second-level review may be triggered by various factors, such as high-risk or high-dollar accounts, coding quality indicators, payer requirements, or internal audit findings1. One of the factors that is most likely to trigger a second-level review is a record with multiple major complicating conditions (MCCs)2. MCCs are diagnoses that significantly affect the severity of illness and resource utilization of a patient, and are assigned a higher relative weight in the DRG system3. A record with multiple MCCs may indicate a complex or unusual case that requires additional validation and verification of the coding and documentation. A record with multiple MCCs may also affect the reimbursement, risk adjustment, and quality scores of the hospital, and therefore may be subject to external scrutiny or audit4. The other options are not as likely to trigger a second-level review, as they are not as indicative of coding or documentation issues or risks. A procedure code that increases reimbursement may not necessarily require a second-level review, unless it is inconsistent with the documentation or the clinical indicators. A diagnosis that impacts a quality-of-care measure may be relevant for CDI purposes, but not necessarily for coding validation.
An account coded before the discharge summary is available may be incomplete or inaccurate, but it may also be corrected or updated before final billing.
CDIP Exam Preparation Guide - AHIMA
Building a Resilient CDI: Second Level Review
Major Complications or Comorbidities (MCC) & Complications or Comorbidities (CC) | CMS Demystifying and communicating case-mix index - ACDIS


NEW QUESTION # 93
A patient was admitted with complaints of confusion, weakness, and slurred speech. A CT of the head and MRI were performed and resulted in normal findings. Daily aspirin was administered and a speech therapy evaluation was conducted. The final diagnosis on discharge was transient ischemic attack, and cerebrovascular disease was ruled out. What is the correct diagnostic related group assignment?

Answer: A

Explanation:
Explanation
Transient ischemic attack (TIA) is a neurological event with the signs and symptoms of a stroke, but which go away within a short period of time. TIA is assigned to DRG 069, which is a medical DRG. Cerebrovascular disease was ruled out, so it cannot be coded as a secondary diagnosis. The other options are incorrect because they do not reflect the principal diagnosis of TIA.


NEW QUESTION # 94
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