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AHIMA Certified Documentation Integrity Practitioner Sample Questions (Q121-Q126):

NEW QUESTION # 121
AHIMA suggests which of the following for an organization to consider as physician response rate and agreement rate?

A. 70%/50%
B. 80%/40%
C. 75%/75%
D. 80%/80%

Answer: D

Explanation:
Explanation
AHIMA suggests that an organization should consider a physician response rate of 80% and an agreement rate of 80% as benchmarks for CDI program performance. These rates indicate the level of physician engagement and documentation accuracy in relation to CDI queries.
References: AHIMA. "Guidelines for Achieving a Compliant Query Practice (2019 Update)." Journal of AHIMA 90, no. 2 (February 2019): 20-29.

NEW QUESTION # 122
A query should include

A. relevant clinical indicators
B. the impact of reimbursement
C. the impact on quality
D. information from previous encounters

Answer: A

Explanation:
Explanation
A query should include relevant clinical indicators from the health record that support the need for clarification and the query options. Clinical indicators are objective and measurable signs, symptoms, laboratory results, diagnostic test results, medications, treatments, and other documented findings that are related to a specific diagnosis or condition. Information from previous encounters, the impact on quality, and the impact of reimbursement are not appropriate to include in a query, as they may introduce bias, lead the provider, or imply a desired response.

NEW QUESTION # 123
A resident returns to the long-term care facility following hospital care for pneumonia. The physician's orders and progress note state "Continue IV antibiotics for pneumonia - 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia". Is it appropriate to code the pneumonia in this scenario?

A. Yes, J18.9, Pneumonia, unspecified organism, Z79.2 should be coded along with long term antibiotics
B. No, since the patient needed a repeat x-ray, the condition does not clarify as a diagnosis
C. Yes J18.8, Pneumonia, other specified organism
D. Yes, J18.9, Pneumonia, unspecified organism, should be coded until the condition is resolved

Answer: A

Explanation:
Explanation
It is appropriate to code the pneumonia in this scenario because the condition is still present and being treated at the time of admission to the long-term care facility. According to the ICD-10-CM Official Guidelines for Coding and Reporting, a diagnosis is reportable if it is documented as "present on admission" or "active" by the provider, or if it requires or affects patient care treatment or management 2. In this case, the pneumonia is still active and requires IV antibiotics and a repeat x-ray, which indicates that it affects the patient care treatment and management. Therefore, the pneumonia should be coded as J18.9, Pneumonia, unspecified organism, which is the default code for pneumonia when no causal organism is identified 3. In addition, the code Z79.2, Long term (current) use of antibiotics, should be coded to indicate that the patient is receiving long term antibiotic therapy as part of the treatment plan 4.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 138 5 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section I.B.14 3: ICD-10-CM Code J18.9 - Pneumonia, unspecified organism 4: ICD-10-CM Code Z79.2 - Long term (current) use of antibiotics

NEW QUESTION # 124
When benchmarking with outside organizations, the clinical documentation integrity practitioner (CDIP) must determine if the organization is benchmarking with which of the following criteria?

A. Hospital within its region
B. Hospital within its county
C. Hospitals that are its peers
D. Hospital within its state

Answer: C

Explanation:
Explanation
When benchmarking with outside organizations, the clinical documentation integrity practitioner (CDIP) must determine if the organization is benchmarking with hospitals that are its peers because peer hospitals have similar characteristics such as size, location, teaching status, case mix index, and payer mix. Benchmarking with peer hospitals allows for a more accurate and meaningful comparison of performance indicators and outcomes. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2

NEW QUESTION # 125
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. state law
D. organizational policy

Answer: D

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 # 126
......

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