AHIMA CDIP Dumps Updated Apr 20, 2024 WIith 140 Questions
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NEW QUESTION # 20
A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?
- A. Query for protein calorie malnutrition
- B. Query for a diagnosis associated with the dietician's finding of malnutrition
- C. Query if the malignant pleural effusion is the reason for admission
- D. Query for malignant pleural effusion
Answer: D
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement2. In this case, the patient has a large right lung pleural effusion related to lung cancer stage II, which is documented multiple times. However, the documentation does not specify whether the pleural effusion is malignant or not. A malignant pleural effusion is a condition where cancer cells spread to the pleural space and cause fluid accumulation3. A malignant pleural effusion is a major complication or comorbidity (MCC) that affects the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality scores of the hospital4. Therefore, a post discharge query opportunity should be sent to the physician to clarify whether the pleural effusion is malignant or not, based on the clinical indicators such as chest x-ray, thoracentesis, and fluid analysis. The query should provide answer options such as malignant pleural effusion, non-malignant pleural effusion, unable to determine, or other. The other options are not correct because they either do not affect the SOI/ROM of the patient (A and C), or they do not address the specificity of the diagnosis (D). References:
CDIP Exam Preparation Guide - AHIMA
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Malignant Pleural Effusion: Symptoms, Causes, Diagnosis & Treatment Q&A: Coding for malignant pleural effusions | ACDIS
NEW QUESTION # 21
A 100-year-old female presents to the emergency department with altered mental state and a 3-day history of productive cough, shortness of breath, and fever after a witnessed aspiration 3 days ago. The patient lives in custodial care at a nearby skilled nursing facility. Patient was treated with Augmentin at the facility without improvement. Exam is notable for Tc 38.9, blood pressure 142/78, respiratory rate 28, pulse 91. There is accessory muscle use with breathing.
Patient is moaning and disoriented but
otherwise the neurologic exam is nonfocal.
Labs notable for sodium 126, creatinine 0.5. white blood count 17.5, hemoglobin 13, platelet 200. venous blood gas 7.44/32/45/-3 Chest x-ray shows bilateral lower lobe infiltrates and dense right lower lobe consolidation.
Patient is placed on bilevel positive airway pressure and given vancomycin, pip/tazo, levofloxacin.
Discharge Diagnosis: health care associated pneumonia (HCAP), respiratory distress, altered mental status, low sodium Which list of diagnoses require a post-discharge query that will result in a more specific principal diagnosis with the highest level of severity of illness and risk of mortality?
- A. Severe sepsis, hypernatremia, delirium, pneumonia
- B. Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure
- C. Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia
- D. Coma, stroke, HCAP, hypernatremia
Answer: B
Explanation:
Explanation
A post-discharge query is needed to obtain a more specific principal diagnosis with the highest level of severity of illness (SOI) and risk of mortality (ROM) for this patient. The discharge diagnosis of health care associated pneumonia (HCAP) is not specific enough to capture the etiology, site, and severity of the pneumonia. Based on the clinical indicators in the case scenario, such as the history of aspiration, the chest x-ray findings, the elevated white blood count, the fever, and the antibiotic treatment, a more specific diagnosis of aspiration pneumonia would be appropriate. Aspiration pneumonia is a type of pneumonia that occurs when foreign material, such as food or vomit, is inhaled into the lungs, causing inflammation and infection. Aspiration pneumonia has a higher SOI and ROM than HCAP because it is associated with more complications and poorer outcomes 1.
Additionally, the discharge diagnosis of altered mental status is vague and does not reflect the underlying cause or severity of the condition. Based on the clinical indicators in the case scenario, such as the fever, the low sodium level, the moaning and disorientation, and the venous blood gas results, a more specific diagnosis of septic encephalopathy would be appropriate. Septic encephalopathy is a type of delirium that occurs when sepsis affects the brain function, causing confusion, agitation, or reduced consciousness. Septic encephalopathy has a higher SOI and ROM than altered mental status because it indicates a systemic inflammatory response and multi-organ dysfunction 2.
Furthermore, the discharge diagnosis of respiratory distress is also vague and does not reflect the underlying cause or severity of the condition. Based on the clinical indicators in the case scenario, such as the shortness of breath, the accessory muscle use, the respiratory rate, and the bilevel positive airway pressure treatment, a more specific diagnosis of acute hypoxemic respiratory failure would be appropriate. Acute hypoxemic respiratory failure is a type of respiratory failure that occurs when there is insufficient oxygen exchange in the lungs, causing low oxygen levels in the blood. Acute hypoxemic respiratory failure has a higher SOI and ROM than respiratory distress because it indicates a life-threatening condition that requires mechanical ventilation or oxygen therapy 3.
Finally, based on the clinical indicators in the case scenario, such as the fever, the elevated white blood count, and the antibiotic treatment, a diagnosis of sepsis should also be included in the query. Sepsis is a serious complication of infection that occurs when the body's immune system overreacts to an infection and causes widespread inflammation and organ damage. Sepsis has a high SOI and ROM because it can lead to septic shock or death if not treated promptly 4.
Therefore, a post-discharge query should ask the provider to confirm or rule out aspiration pneumonia, hyponatremia (low sodium level), septic encephalopathy, and sepsis with acute hypoxemic respiratory failure as possible diagnoses for this patient. These diagnoses would result in a more specific principal diagnosis with the highest level of SOI and ROM for this patient.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) Aspiration Pneumonia - an overview | ScienceDirect Topics1 Septic Encephalopathy - an overview | ScienceDirect Topics2 Acute Hypoxemic Respiratory Failure - an overview | ScienceDirect Topics3 Sepsis - Symptoms and causes - Mayo Clinic4
NEW QUESTION # 22
Which of the following is an appropriate first step to address physicians with low query response rates?
- A. The physician receives a suspension until query responses are improved
- B. The medical staff review the physician's noncompliance to consider sanctions
- C. A meeting between the physician advisor/champion and the noncompliant physician
- D. An educational session between the clinical documentation integrity practitioner (CDIP) and physician
Answer: D
Explanation:
Explanation
An appropriate first step to address physicians with low query response rates is an educational session between the clinical documentation integrity practitioner (CDIP) and physician because it provides an opportunity to explain the purpose and benefits of the query process, to identify and address any barriers or challenges to responding, and to offer feedback and guidance on how to improve query response rates. An educational session can also help to build rapport and trust between the CDIP and the physician, and to demonstrate respect and professionalism. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Understanding CDI Metrics3
NEW QUESTION # 23
Which of the following is a clinical documentation element supporting a transbronchial biopsy?
- A. Length of procedure
- B. Pathology report documenting alveolar tissue
- C. Hemoptysis
- D. Pathology report documenting bronchial tissue
Answer: B
Explanation:
Explanation
A transbronchial biopsy is a procedure that involves obtaining tissue samples from the alveoli (air sacs) of the lungs through a bronchoscope. A pathology report documenting alveolar tissue is a clinical documentation element that supports a transbronchial biopsy, as it confirms the source and nature of the tissue sample.
References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 55-56.
NEW QUESTION # 24
Review the following query to determine if it is compliant:
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Dehydration
Hyponatremia
Hypernatremia
Chronic kidney disease (indicate stage)
Other (please specify)
- A. Yes, query is compliant as it provides clinical indicators and several options for response.
- B. Yes, query is compliant as it offers the minimum number of multiple-choice answers ..
- C. No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.
- D. No, query is noncompliant as it does not provide the option of "unable to determine".
Answer: C
Explanation:
Explanation
A query is noncompliant if it includes options that are not supported by the clinical indicators or the patient's condition. In this case, hypernatremia is a condition of high sodium level, not low sodium level, and it is not consistent with the treatment of 0.9% saline IV. Therefore, it is a clinically irrelevant option that may confuse or mislead the provider. A compliant query should only include options that are reasonable and plausible based on the available documentation and evidence. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3
NEW QUESTION # 25
A clinical documentation integrity practitioner (CDIP) is developing a plan to promote the CDI program throughout a major hospital. It is proving challenging to find support. What is a primary step for the CDIP?
- A. Determine primary interests and needs as requested
- B. Teach coding classes to the new physicians as needed
- C. Teach nursing staff about documentation integrity
- D. Determine primary interests of an individual or department
Answer: D
Explanation:
Explanation
A primary step for the CDIP to promote the CDI program throughout a major hospital is to determine the primary interests of an individual or department that could benefit from or support the CDI program. This is because different stakeholders may have different motivations, expectations, and challenges related to CDI, and the CDIP should tailor the communication and education strategies accordingly. For example, physicians may be interested in how CDI can improve their quality metrics, reimbursement, and patient outcomes; coders may be interested in how CDI can reduce coding errors, denials, and queries; and executives may be interested in how CDI can enhance revenue integrity, compliance, and reputation. By identifying the primary interests of each individual or department, the CDIP can demonstrate the value and relevance of the CDI program, address any barriers or concerns, and foster collaboration and engagement 23.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: How to Promote Your Clinical Documentation Improvement Program 3: How to Market Your Clinical Documentation Improvement Program
NEW QUESTION # 26
Which of these medical conditions would a clinical documentation integrity practitioner (CDIP) expect to be treated with Levophed?
- A. Acute respiratory failure
- B. Acute kidney failure
- C. Septic shock
- D. Multiple sclerosis
Answer: C
Explanation:
Explanation
Levophed is a brand name of norepinephrine, a medication that is similar to adrenaline and acts as a vasopressor, meaning that it constricts blood vessels and increases blood pressure. Levophed is indicated to raise blood pressure in adult patients with severe, acute hypotension (low blood pressure) that can occur with certain medical conditions or surgical procedures1. One of these conditions is septic shock, which is a life-threatening complication of sepsis, a systemic inflammatory response to infection. Septic shock is characterized by persistent hypotension despite adequate fluid resuscitation, along with signs of organ dysfunction and tissue hypoperfusion. Levophed is used as a first-line vasopressor agent in septic shock to restore adequate perfusion pressure and tissue oxygenation.
Acute respiratory failure, multiple sclerosis, and acute kidney failure are not indications for Levophed treatment. Acute respiratory failure is a condition in which the lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from the blood. It can be caused by various lung diseases, injuries, or infections. The treatment of acute respiratory failure depends on the underlying cause and the severity of the condition, but it may include oxygen therapy, mechanical ventilation, medications to treat infections or inflammation, or other supportive measures. Multiple sclerosis is a chronic autoimmune disease that affects the central nervous system, causing inflammation, demyelination, and axonal damage. The symptoms of multiple sclerosis vary depending on the location and extent of the nerve damage, but they may include vision problems, numbness, weakness, fatigue, cognitive impairment, or pain. The treatment of multiple sclerosis aims to reduce the frequency and severity of relapses, slow the progression of disability, and manage the symptoms. It may include immunomodulatory drugs, corticosteroids, symptomatic medications, physical therapy, or other interventions. Acute kidney failure is a condition in which the kidneys suddenly lose their ability to filter waste products and fluids from the blood. It can be caused by various factors that impair the blood flow to the kidneys, damage the kidney tissue, or block the urine output. The symptoms of acute kidney failure may include decreased urine output, fluid retention, nausea, confusion, or shortness of breath. The treatment of acute kidney failure depends on the underlying cause and the severity of the condition, but it may include fluid management, electrolyte replacement, dialysis, medications to treat infections or inflammation, or other supportive measures.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Levophed Uses, Side Effects & Warnings - Drugs.com Levophed (Norepinephrine Bitartrate): Uses, Dosage ... - RxList Levarterenol, Levophed (norepinephrine) dosing ... - Medscape
[Septic Shock: Practice Essentials ... - Medscape Reference]
[Surviving Sepsis Campaign: International Guidelines for ... - PubMed]
[Acute respiratory failure: MedlinePlus Medical Encyclopedia]
[Multiple sclerosis - Symptoms and causes - Mayo Clinic]
[Acute kidney failure - Symptoms and causes - Mayo Clinic]
NEW QUESTION # 27
A patient presents to the emergency room with acute shortness of breath. The patient has a history of lung cancer that has been treated previously with radiation and chemotherapy. The patient is intubated and placed on mechanical ventilation. A chest x-ray is remarkable for a pleural effusion. A thoracentesis is performed, and the cytology results show malignant cells. Diagnoses on discharge: Acute respiratory failure due to recurrence of small cell carcinoma and malignant pleural effusion. Which coding reference takes precedence for assigning the ICD-10-CM/PCS codes?
- A. AMA CPT Assistant
- B. ICD-10-CM Official Guidelines for Coding and Reporting
- C. AHA Coding Clinic for ICD-10-CM/PCS
- D. Conventions and instructions of the classification for ICD-10-CM/PCS
Answer: D
Explanation:
Explanation
According to the CDIP Exam Content Outline, one of the tasks of a clinical documentation integrity practitioner (CDIP) is to apply coding conventions, guidelines, and definitions for ICD-10-CM/PCS. Coding conventions are the general rules for the use of the classification system, such as the use of abbreviations, punctuation, symbols, and sequencing instructions. Coding guidelines are the official rules for selecting and reporting codes based on the documentation in the health record. Coding definitions are the explanations of the terms and concepts used in the classification system. The conventions and instructions of the classification for ICD-10-CM/PCS take precedence over any other coding reference because they are the primary source of coding rules and standards. The other coding references, such as AMA CPT Assistant, AHA Coding Clinic for ICD-10-CM/PCS, and ICD-10-CM Official Guidelines for Coding and Reporting, are secondary sources that provide additional guidance, clarification, or interpretation of the coding conventions and instructions.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) ICD-10-CM Features | Diagnosis Coding: Using the ICD-10-CM1
NEW QUESTION # 28
A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate
- A. aftercare
- B. subsequent
- C. sequela
- D. initial
Answer: A
Explanation:
Explanation
The ICD-10-CM 7th character code value should indicate aftercare for a patient who falls off a ladder and undergoes a right femur procedure, and then returns to the hospital for removal of the external fixation device.
Aftercare codes are used to capture encounters for follow-up care after completed treatment of an injury or condition, such as removal of external fixation devices, casts, or pins. Aftercare codes are not used for subsequent encounters for complications or infections related to the injury or condition5 References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 5:
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 29
Educating physicians on severity of illness and risk of mortality is best accomplished by utilizing
- A. the DRG Expert
- B. physician report cards
- C. case studies
- D. the case mix index
Answer: C
Explanation:
Explanation
Educating physicians on severity of illness and risk of mortality is best accomplished by using case studies that demonstrate how documentation affects these indicators and how they impact patient care, quality outcomes, and reimbursement.
References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 97-98.
NEW QUESTION # 30
The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the
- A. organization's medical and surgical staff
- B. Health Information Management coding staff
- C. clinical documentation integrity staff
- D. organization senior administration staff
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 # 31
Which of the following diagnosis is MOST likely to trigger a second level review?
- A. Acute kidney injury
- B. Heart failure
- C. Pneumonia
- D. Malnutrition
Answer: D
Explanation:
Explanation
Malnutrition is a diagnosis that is most likely to trigger a second level review because it affects the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality measures of the hospital. Malnutrition also requires clinical validation and clear documentation of its etiology, type, degree, and duration2 References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 2:
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 32
A key physician approaches the director of the coding department about the new emphasis associated with clinical documentation integrity (CDI). The physician does not support the program and believes the initiative will encourage inappropriate billing.
How should the director respond to the concerns?
- A. Involve the physician advisor/champion in addressing the medical staff's concerns
- B. Refer the physician to the finance department to discuss required billing changes
- C. Inform the physician that changes must be made
- D. Develop an administrative panel to oversee CDI process
Answer: A
Explanation:
Explanation
The director should involve the physician advisor/champion in addressing the medical staff's concerns because the physician advisor/champion is a key member of the CDI team who can provide clinical expertise, education, and leadership to promote CDI among physicians. The physician advisor/champion can help to explain the goals and benefits of CDI, such as improving patient care quality, accuracy of documentation, and appropriate reimbursement. The physician advisor/champion can also address any misconceptions or fears that the physicians may have about CDI, such as encouraging inappropriate billing or increasing their workload.
The physician advisor/champion can serve as a liaison between the CDI team and the medical staff, and foster a culture of collaboration and trust.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) CDIP Exam Preparation Guide (https://my.ahima.org/store/product?id=67077)
NEW QUESTION # 33
Whether or not queries should be kept as a permanent part of the medical record is decided by
- A. federal law
- B. physician preference
- C. organizational policy
- D. state law
Answer: C
Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, whether or not queries should be kept as a permanent part of the medical record is decided by the organizational policy of each facility1. There is no federal or state law that mandates the retention of queries in the medical record, although some external reviewers may request copies of queries to validate the query wording and compliance2. Physician preference is not a valid factor in determining the query retention policy, as queries should be handled consistently across the organization3. Therefore, the correct answer is D. organizational policy. References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Q&A: Develop policies regarding query retention | ACDIS Q&A: Keep query retention policies consistent | ACDIS
NEW QUESTION # 34
While reviewing a chart, a clinical documentation integrity practitioner (CDIP) needs to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes
1 and 2. Which coding reference should be used?
- A. ICD-10-CM Official Guidelines for Coding and Reporting
- B. AMA CPT Assistant
- C. AHA Coding Clinic for ICD-10-CM
- D. Faye Brown's Coding Handbook
Answer: A
Explanation:
Explanation
The coding reference that should be used to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes 1 and 2 is the ICD-10-CM Official Guidelines for Coding and Reporting. This document provides the conventions and instructions for the proper use of the ICD-10-CM classification system, including the definitions and examples of the Includes Notes and Excludes Notes 1 and 2. The document is updated annually by the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), and is available online at 2. The other coding references listed are not specific to ICD-10-CM or do not contain the general rules for the Includes Notes and Excludes Notes 1 and 2.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 4
NEW QUESTION # 35
What type of laboratory test is a creatinine test?
- A. Chemistry
- B. Hematology
- C. Serology
- D. Microbiology
Answer: A
NEW QUESTION # 36
Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?
- A. Query the physician to see if acute renal failure with tubular necrosis is supported
- B. Code acute renal failure since symptoms are there and documented
- C. No query is needed because the patient was dehydrated
- D. Query the physician to see if acute renal failure is clinically supported
Answer: D
Explanation:
Explanation
The appropriate action in this case is to query the physician to see if acute renal failure is clinically supported.
This is because the patient has signs and symptoms of acute renal failure, such as oliguria, pulmonary edema, and elevated creatinine, but the diagnosis is not documented in the medical record. Acute renal failure is a clinical syndrome characterized by a rapid decline in kidney function and accumulation of metabolic waste products. It can be caused by various factors, such as dehydration, hypovolemia, sepsis, nephrotoxins, or obstruction. Acute renal failure can be classified according to the RIFLE criteria (Risk, Injury, Failure, Loss, End-stage kidney disease) or the AKIN criteria (Acute Kidney Injury Network), which are based on changes in serum creatinine and urine output 23. A query to the physician is needed to confirm or rule out the diagnosis of acute renal failure, specify the etiology and severity of the condition, and document any associated complications or comorbidities. A query to the physician will also improve the accuracy and completeness of the documentation and coding, and reflect the true clinical picture and resource utilization of the patient.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: Acute Kidney Injury: Diagnosis and Management | AAFP 3: AKIN Classification for Acute Kidney Injury (AKI) - MDCalc
NEW QUESTION # 37
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