AHIMA CDIP Dumps – The Sure Way To Pass Exam [Q14-Q31]

NEW QUESTION 14
A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient’s severity of illness (SOI) and risk of mortality (ROM)?

Query the physician to clarify if CXR result means patient has pneumonia.

Query the physician to clarify for type of COPD such as severe asthma.

Query the physician to clarify for clinical significance of the CXR results.

Query the physician to clarify if patient has acute COPD exacerbation.

NEW QUESTION 15
A clinical documentation integrity practitioner (CDIP) has been successful in getting physicians to respond to queries. However, when the CDIP poses a query to a specific doctor, there is no response at all. The CDIP has tried face-to-face conversations, calling, emails, texts, but still gets no response. What is the next step the CDIP should take?

Elevate the issue to the physician advisor/champion after the CDI supervisor has reviewed the case and deemed the query appropriate

Report the doctor to the Vice President of Medical Affairs so the doctor understands the importance of clinical documentation

Hold a meeting with the CDI director and the doctor to find out why the doctor is not responding to the queries

Warn the other CDIPs that the doctor is a non-responder and to forego querying

NEW QUESTION 16
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?

Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia

Coma, stroke, HCAP, hypernatremia

Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure

Severe sepsis, hypernatremia, delirium, pneumonia

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 17
A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?

Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add ‘morbid obesity with BMI 42 kg/m2’ to your next progress note.

Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add ‘morbid obesity with BMI 42 kg/m2’ to your next progress note.

Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient’s morbid obesity was present on admission and add the diagnosis to future progress notes?

Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)

NEW QUESTION 18
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?

Develop an administrative panel to oversee CDI process

Refer the physician to the finance department to discuss required billing changes

Involve the physician advisor/champion in addressing the medical staff’s concerns

Inform the physician that changes must be made

NEW QUESTION 19
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?

Determine primary interests and needs as requested

Determine primary interests of an individual or department

Teach coding classes to the new physicians as needed

Teach nursing staff about documentation integrity

NEW QUESTION 20
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?

093 Other Disorders of Nervous System without CC/MCC

948 Signs and Symptoms without MCC

069 Transient Ischemia

066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC

NEW QUESTION 21
Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include

performing data analysis

developing query forms

educating physicians

querying physicians

NEW QUESTION 22
What type of laboratory test is a creatinine test?

Chemistry

Microbiology

Hematology

Serology

NEW QUESTION 23
What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

Multiple-choice

Open-ended

Verbal

Yes/No

NEW QUESTION 24
Proposed changes to the inpatient prospective payment system (IPPS) take effect on

October 1

January 1

July 1

April 1

NEW QUESTION 25
Creating policies and procedures for the query process will help eliminate

confusion

risk

indecision

duplication

NEW QUESTION 26
A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition. Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?

61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural

61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma

61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion

61105 Twist drill hole subdural/ventricular puncture

NEW QUESTION 27
Which physician would best benefit from additional education for unanswered queries?

Dr. A

Dr. B

Dr. C

Dr. D

NEW QUESTION 28
A hospital administrator has hired a clinical documentation integrity (CDI) firm to improve its revenue objectives. The physicians object to this action. How should the firm collaborate with physicians to overcome their objections?

Create a vision statement that outlines the project objectives

Communicate the benefits of the CDI firm about the project

Hire a consultant to communicate the benefits to the physicians

Identify an influential physician advisor/champion to promote support

Explanation
A physician advisor/champion is a physician leader who supports and advocates for the CDI program and its objectives. A physician advisor/champion can help overcome the objections of other physicians by providing education, feedback, guidance, and mentorship on documentation best practices and their impact on revenue, quality, and patient care. A physician advisor/champion can also act as a liaison between the CDI firm and the medical staff, resolve conflicts or discrepancies in documentation, and foster a culture of collaboration and improvement. Physicians are more likely to trust and engage with their peers who understand their clinical perspective and challenges, rather than an external CDI firm that may be perceived as intrusive or disruptive.
A:Create a vision statement that outlines the project objectives. This is not sufficient to collaborate with physicians and overcome their objections. A vision statement is a general statement that describes the desired outcome of the project, but it does not address the specific concerns or questions that physicians may have about the CDI firm’s role, methods, or benefits.
B:Communicate the benefits of the CDI firm about the project. This is not enough to collaborate with physicians and overcome their objections. Communicating the benefits of the CDI firm may be informative, but it may not be persuasive or credible if it comes from the CDI firm itself, without any endorsement or support from a physician leader within the organization.
C: Hire a consultant to communicate the benefits to the physicians. This is not a good way to collaborate with physicians and overcome their objections. Hiring a consultant may add another layer of complexity and cost to the project, and it may not improve the trust or relationship between the CDI firm and the physicians. A consultant may also lack the clinical expertise or authority to influence the physicians’ behavior or attitude.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Q&A: Defining roles for physician advisor/champion | ACDIS Q&A: The Role of the Physician Advisor in CDI | ACDIS The Role of a Physician Advisor – UASI Solutions PA/NP in Physician Champion / Advisor Role – ACDIS Forums

NEW QUESTION 29
Which entity has the following regulation?
A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

Centers for Medicare & Medicaid Services

Office for Civil Rights

Office of the National Coordinator for Health Information Technology

Office of Inspector General

NEW QUESTION 30
The BEST place for the provider to document a query response is which of the following?

The query form

The next progress note and the problem list

The next progress note and all subsequent notes including the discharge summary

An addendum to the history and physical

NEW QUESTION 31
Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?

Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)

Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)