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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Compliance | 4–8% | - Legal and ethical documentation practices - Compliance monitoring and reporting - AHIMA standards and regulatory requirements - Fraud and abuse prevention |
| Topic 2: Leadership | 17–22% | - Interdisciplinary collaboration - Provider engagement and communication - CDI program development and promotion - Policy and procedure creation |
| Topic 3: Research & Education | 11–15% | - Regulatory and guideline updates - Best practice research and implementation - Documentation improvement training materials - Provider and staff education |
| Topic 4: CDI Metrics & Statistics | 14–18% | - Benchmarking and reporting - Quality audits and compliance monitoring - Query response and volume tracking - DRG comparison and denial analysis |
| Topic 5: Record Review & Document Clarification | 24–28% | - POA, HAC, SOI, ROM clarification - Identify documentation gaps and specificity issues - Query tracking and follow-up - Ethical provider query development - Compliance with query standards |
| Topic 6: Clinical Coding Practice | 22–26% | - Principal and secondary diagnosis identification - DRG, CPT, and HCPCS code assignment - ICD-10-CM/PCS coding conventions and guidelines - Coding software and reference resources - Payer requirements and reimbursement models |
1. 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) organization senior administration staff
D) clinical documentation integrity staff
2. Which of the following is nonessential to facilitate code capture when educating clinical staff on documentation practices associated with diabetes mellitus?
A) Type
B) Cause
C) Manifestation
D) Age
3. Which of the following is an appropriate first step to address physicians with low query response rates?
A) The medical staff review the physician's noncompliance to consider sanctions
B) The physician receives a suspension until query responses are improved
C) An educational session between the clinical documentation integrity practitioner (CDIP) and physician
D) A meeting between the physician advisor/champion and the noncompliant physician
4. A 70-year-old severely malnourished nursing home patient is admitted for a pressure ulcer covered by eschar on the right hip. The provider is queried to clarify the stage of the pressure ulcer. Because the wound has not been debrided, the provider responds "unable to determine".
How will the stage of this pressure ulcer be coded?
A) Undetermined stage pressure ulcer
B) Stage IV pressure ulcer
C) Unstageable pressure ulcer
D) Stage III pressure ulcer
5. Which of the following should be examined when developing documentation integrity projects?
A) CC and MCC capture rates
B) Physician satisfaction surveys
C) Query rates from coding staff
D) Coding productivity statistics
Solutions:
| Question # 1 Answer: A | Question # 2 Answer: D | Question # 3 Answer: C | Question # 4 Answer: C | Question # 5 Answer: A |
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Certified Documentation Integrity Practitioner
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