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NEW QUESTION # 44
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 # 45
Which of the following is the definition of an Excludes 2 note in ICD-10-CM?
- A. Neither of the codes can be assigned
- B. This is not a convention found in ICD-10-CM
- C. Two codes can be used together to completely describe the condition
- D. Only one code can be assigned to completely describe the condition
Answer: C
Explanation:
Explanation
An Excludes 2 note in ICD-10-CM indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together to completely describe the condition. For example, under code R05 Cough, there is an Excludes 2 note for whooping cough (A37.-). This means that a patient can have both a cough and whooping cough at the same time, and both codes can be used together to capture the full clinical picture.
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 # 46
Given the following ICD-10-CM Alphabetical Index entry:
Ectopic (pregnancy) 008.9
What is the meaning of the parenthesis?
- A. Non-essential modifiers
- B. Inclusion notes
- C. Essential modifiers
- D. Exclusion notes
Answer: A
NEW QUESTION # 47
The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.
What should the CDI manager keep in mind when discussing this observation with physicians?
- A. The query response rate directly correlates to quality reports.
- B. The query rate is too high while the agreement rate is low.
- C. The diagnosis with a higher degree of specificity has a lower severity of illness.
- D. The indicator is a key factor of measurement for quality reports.
Answer: D
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, one of the CDI metrics and statistics that CDI managers should track and interpret is the severity level measured against average length of stay (ALOS)1. This indicator reflects the complexity and acuity of the patient population and the quality of care provided by the hospital2. A low-severity level with a high ALOS may indicate under-documentation or under-coding of the patient's condition, which may affect the hospital's reimbursement, risk adjustment, and quality scores3. Therefore, the CDI manager should keep in mind that this indicator is a key factor of measurement for quality reports when discussing this observation with physicians, and educate them on the importance of documenting and coding accurately and completely to reflect the patient's true severity of illness. The other options are not correct because they do not address the issue of severity level measured against ALOS, or they are not relevant to the CDI manager's role or responsibility. References:
CDIP Exam Preparation Guide - AHIMA
Demystifying and communicating case-mix index - ACDIS
Severity of Illness: What Is It? Why Is It Important? | HCPro
NEW QUESTION # 48
When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?
- A. Admitting
- B. Consulting
- C. Surgical
- D. Credentialing
Answer: A
Explanation:
Explanation
When queries are part of the health record, which is recommended by AHIMA and ACDIS, physicians are responsible for responding to queries in a timely manner and ensuring that their documentation is complete and accurate. If a provider receives too many deficiencies due to incomplete records for failure to respond to queries, their admitting privilege could be suspended by the medical staff committee as a disciplinary action.
References: AHIMA/ACDIS. "Guidelines for Achieving a Compliant Query Practice (2019 Update)." Journal of AHIMA 90, no. 2 (February 2019): 20-29.
NEW QUESTION # 49
Which of the following indicates a noncompliant multiple-choice query? One that does NOT
- A. include the option of "unable to determine"
- B. allow the provider to add their own response
- C. list options in alphabetical order
- D. include at least four options
Answer: D
Explanation:
Explanation
A noncompliant multiple-choice query is one that does not include at least four options because it may limit the provider's choice and suggest a preferred answer. A compliant multiple-choice query should include at least four options that are clinically significant, reasonable, and plausible based on the clinical indicators and documentation in the health record. The options should also be listed in alphabetical order to avoid any bias or preference. A compliant multiple-choice query should also allow the provider to add their own response if none of the options are appropriate, and include the option of "unable to determine" if the provider cannot make a definitive diagnosis based on the available information. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Guidelines for Achieving a Compliant Query Practice (2019 Update)3
NEW QUESTION # 50
A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is
- A. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.
- B. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment. - C. Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other. - D. Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.
Answer: C
Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, a compliant query should provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement1. Option C meets these criteria, as it provides a list of possible diagnoses that are relevant to the patient's condition and asks the provider to indicate which one they are treating. Option C also does not imply or suggest a preferred answer or outcome, and allows the provider to choose unable to determine or other if none of the listed options apply. Option A is not compliant, as it does not provide any answer options and implies that the provider should order more tests to capture a higher severity of illness. Option B is not compliant, as it provides only one answer option and suggests that the provider should document it based on the clinical indicators. Option D is not compliant, as it provides only one answer option and implies that the provider should document it based on the indications. References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
NEW QUESTION # 51
When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?
- A. Executive oversight
- B. Coder and CDIP interaction
- C. Physician and CDIP interaction
- D. Physician advisor/champion involvement
Answer: B
Explanation:
Explanation
According to the AHIMA/ACDIS Query Practice Brief, one of the fundamental elements that must be in place for a successful DRG discrepancy resolution is a collaborative and respectful interaction between the coder and the CDIP1. The coder and the CDIP should communicate effectively and timely to identify and resolve any DRG mismatches, using evidence-based guidelines, coding conventions, and query standards1. The coder and the CDIP should also share their knowledge and expertise with each other, and seek clarification from the provider or the physician advisor/champion when necessary1. The other options are not considered fundamental elements for DRG discrepancy resolution, although they may be helpful or supportive in some situations. References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
NEW QUESTION # 52
A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?
- A. The associated diagnosis directly on the query form
- B. A cause-and-effect relationship between anemia and the underlying cause
- C. That the blood loss was not clinically significant
- D. The associated diagnosis and the clinical rationale in the progress notes
Answer: D
Explanation:
Explanation
The physician needs to document the associated diagnosis and the clinical rationale in the progress notes for the CDIP to record the query as answered and agreed because this is the best way to ensure that the health record reflects the patient's condition and treatment accurately and completely. The associated diagnosis is the condition that caused or contributed to the blood loss and the need for transfusion, such as acute blood loss anemia, hemorrhage, or trauma. The clinical rationale is the explanation of how the diagnosis is supported by the clinical indicators, such as laboratory values, vital signs, symptoms, or procedures. Documenting the associated diagnosis and the clinical rationale in the progress notes also helps to avoid any confusion or inconsistency with other parts of the health record, such as the discharge summary or the coding. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Guidelines for Achieving a Compliant Query Practice (2019 Update)3
NEW QUESTION # 53
The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?
- A. Audit cases for missed diagnosis by the CDI practitioner to target in the education plan
- B. Audit cases that have high SOI/ROM assigned by coders for education and follow-up
- C. Audit focused APR-DRGs and develop education plan for CDI team and physicians
- D. Audit focused cases by physicians that have a higher SOI/ROM for education plan
Answer: C
Explanation:
Explanation
APR-DRGs are a patient classification system that assigns each inpatient stay to one of more than 300 base APR-DRGs, and then further stratifies each base APR-DRG into four levels of severity of illness (SOI) and risk of mortality (ROM), based on the number, nature, and interaction of complications and comorbidities (CCs) and major CCs (MCCs). SOI reflects the extent of physiologic decompensation or organ system loss of function, while ROM reflects the likelihood of dying. Both SOI and ROM are used to adjust payment rates, quality indicators, and performance measures for hospitals and other healthcare providers.
The CDI manager can gain more information about the potential opportunities for improvement by auditing focused APR-DRGs that have a high impact on SOI/ROM levels, such as those that have a large variation in relative weights across the four severity levels, or those that have a high frequency or volume of cases. The audit can help identify the documentation gaps, inconsistencies, or inaccuracies that may affect the assignment of SOI/ROM levels, such as missing, vague, or conflicting diagnoses, procedures, or clinical indicators. The audit can also help evaluate the CDI team's performance in terms of query rate, response rate, agreement rate, and accuracy rate. Based on the audit findings, the CDI manager can develop an education plan for both the CDI team and the physicians to address the specific documentation improvement areas and provide feedback and guidance on best practices.
A: Audit cases for missed diagnosis by the CDI practitioner to target in the education plan. This is not the best way to gain more information about the situation, because it may not capture all the factors that affect SOI/ROM levels, such as procedures, clinical indicators, or interactions among diagnoses. It may also focus only on the CDI practitioner's performance, without considering the physician's role in documentation quality and completeness.
B: Audit focused cases by physicians that have a higher SOI/ROM for education plan. This is not a valid way to gain more information about the situation, because it may not identify the documentation improvement opportunities for cases that have a lower SOI/ROM than expected, based on their clinical complexity and acuity. It may also create a perception of bias or favoritism among physicians, if only some are selected for audit and education.
C: Audit cases that have high SOI/ROM assigned by coders for education and follow-up. This is not a reliable way to gain more information about the situation, because it may not reflect the true SOI/ROM levels of the cases, if there are errors or discrepancies in coding or grouping. It may also overlook the documentation improvement opportunities for cases that have low SOI/ROM assigned by coders, despite having high clinical complexity and acuity.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
3M™ All Patient Refined Diagnosis Related Groups (APR DRGs) | 3M United States Q&A: Understanding SOI and ROM in the APR-DRG system | ACDIS Use SOI/ROM scores to enhance CDI program effectiveness | ACDIS
NEW QUESTION # 54
The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA's Guidelines for Achieving a Compliant Query Practice?
- A. Complete the documentation at the end of the day when entering cases reviewed
- B. Complete the documentation at the time of discussion or immediately following
- C. Complete the documentation immediately after the provider's response
- D. Complete the documentation when there is a provider agreement
Answer: B
Explanation:
Explanation
According to AHIMA's Guidelines for Achieving a Compliant Query Practice, the clinical documentation integrity practitioner (CDIP) should complete the documentation at the time of discussion or immediately following to avoid a compliance risk for this follow up failure. This is because verbal queries are considered part of the health record and must be documented in a timely and accurate manner to reflect the provider's response and any changes in documentation or coding. Completing the documentation later or only when there is an agreement may result in errors, omissions, inconsistencies, or delays that may affect the quality and integrity of the health record and the query process. (AHIMA Guidelines for Achieving a Compliant Query Practice1) References:
AHIMA Guidelines for Achieving a Compliant Query Practice1
NEW QUESTION # 55
A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?
- A. Bring together a team of physicians and informatics specialists
- B. Alert senior leadership to the record documentation problem
- C. Gather data on the incidence of inaccurate record documentation
- D. Recommend the physicians to be involved in the project
Answer: C
Explanation:
Explanation
The first step the CDI director should take is to gather data on the incidence of inaccurate record documentation because it is important to establish the baseline and scope of the problem, as well as to identify the potential causes and consequences of over-using electronic copy and paste. Data collection can help to measure the frequency, severity, and impact of documentation errors, such as inconsistencies, redundancies, contradictions, or omissions. Data collection can also help to determine the best methods and tools for conducting the documentation integrity project, such as audits, surveys, interviews, or software applications. (CDIP Exam Preparation Guide1) References:
CDIP Exam Content Outline2
CDIP Exam Preparation Guide1
NEW QUESTION # 56
When a change in departmental workflow is necessary, the first step is to
- A. define the gaps and solutions
- B. assess the current workflow
- C. set realistic timelines
- D. re-engineer the process
Answer: B
Explanation:
Explanation
The first step in changing a departmental workflow is to assess the current workflow and identify the problems or inefficiencies that need to be addressed. This will help to define the gaps and solutions, set realistic timelines, and re-engineer the process.
References: AHIMA. "CDIP Exam Preparation." AHIMA Press, Chicago, IL, 2017: 125-126.
NEW QUESTION # 57
A modifier may be used in CPT and/or HCPCS codes to indicate
- A. a service or procedure was increased or reduced
- B. a service or procedure was performed in its entirety
- C. a service or procedure was performed by one provider
- D. a service or procedure resulted in expected outcomes
Answer: A
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a modifier is a two-digit numeric or alphanumeric code that may be used in CPT and/or HCPCS codes to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code1. One of the reasons to use a modifier is to indicate that a service or procedure was increased or reduced in comparison to the usual service or procedure2. For example, modifier 22 can be used to report increased procedural services that require substantially greater time, effort, or complexity than the typical service3. The other options are not correct because they do not reflect the purpose of using modifiers. A service or procedure performed in its entirety does not need a modifier, as it is assumed to be the standard service or procedure. A service or procedure resulting in expected outcomes does not affect the coding or reimbursement of the service or procedure. A service or procedure performed by one provider may need a modifier depending on the type of provider, the place of service, and the payer rules, but it is not a general reason to use a modifier. References:
CDIP Exam Preparation Guide - AHIMA
Modifiers: A Guide for Health Care Professionals - CMS
CPT Modifiers: 22 Increased Procedural Services | AAPC
NEW QUESTION # 58
A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0°. On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to
- A. code pseudomonas pneumonia
- B. query the provider to document the etiology of pneumonia
- C. code pneumonia, unspecified
- D. query the provider to see if pseudomonas sepsis is supported by the health record
Answer: B
Explanation:
Explanation
The most appropriate action in this case is to query the provider to document the etiology of pneumonia, which is pseudomonas bacteria. This is because the etiology of pneumonia affects the coding and classification of the condition, as well as the severity of illness, risk of mortality, and reimbursement. According to the ICD-10-CM Official Guidelines for Coding and Reporting, pneumonia should be coded by type whenever possible, and if the type of pneumonia is not documented, then the default code is J18.9, Pneumonia, unspecified organism 2. However, if the type of pneumonia is documented, then a more specific code can be assigned, such as J15.1, Pneumonia due to Pseudomonas 3. Therefore, querying the provider to document the etiology of pneumonia will improve the accuracy and completeness of the documentation and coding, and reflect the true clinical picture of the patient.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 139 4 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section I.C.9.a 3: ICD-10-CM Code J15.1 - Pneumonia due to Pseudomonas
NEW QUESTION # 59
Which of the following is a clinical documentation element supporting a transbronchial biopsy?
- A. Pathology report documenting alveolar tissue
- B. Pathology report documenting bronchial tissue
- C. Length of procedure
- D. Hemoptysis
Answer: A
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 # 60
An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are
- A. PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure - B. PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure - C. PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion - D. PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion
Answer: D
Explanation:
Explanation
According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023, the principal diagnosis is defined as "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"2. In this case, the patient was admitted with shortness of breath, productive yellow sputum, and a temperature of 101.2, which are signs and symptoms of pneumonia. The CXR confirmed the diagnosis of LLL pneumonia, which is a serious condition that requires inpatient care. Therefore, LLL pneumonia is the principal diagnosis.
The secondary diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay"2. In this case, the patient had bilateral pleural effusion and kidney failure at the time of admission, which are coexisting conditions that affect the treatment received and/or the length of stay. The renal consult documented AKI with ATN, which is a more specific diagnosis than kidney failure and reflects the severity and etiology of the condition. Therefore, AKI with ATN and bilateral pleural effusion are secondary diagnoses.
References:
CDI Week 2020 Q&A: CDI and key performance indicators1
ICD-10-CM Official Guidelines for Coding and Reporting FY 20232
NEW QUESTION # 61
Which of the following sources provide external benchmarks to examine the effectiveness of a facility's clinical documentation program?
- A. Medicare Provider Analysis and Review
- B. Health Care Financing Administration
- C. American Health Information Management Association
- D. Agency for Healthcare Research and Quality
Answer: D
Explanation:
Explanation
The Agency for Healthcare Research and Quality (AHRQ) provides external benchmarks to examine the effectiveness of a facility's clinical documentation program by developing and disseminating quality indicators (QIs) that measure various aspects of health care quality, such as patient safety, outcomes, efficiency, and effectiveness. These QIs are based on administrative data and can be used to compare the performance of different health care providers or facilities across the nation. The QIs include inpatient quality indicators (IQIs), patient safety indicators (PSIs), prevention quality indicators (PQIs), and pediatric quality indicators (PQIs). These QIs can help clinical documentation improvement (CDI) programs identify areas of improvement, monitor trends, and evaluate the impact of CDI interventions on health care quality 2.
References: 1: Clinical Documentation Improvement Programs: Quality, Efficiency | Deloitte US Analysis 2 2:
AHRQ Quality Indicators 3
NEW QUESTION # 62
Educating physicians on severity of illness and risk of mortality is best accomplished by utilizing
- A. physician report cards
- B. the DRG Expert
- 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 # 63
Which of the following should be examined when developing documentation integrity projects?
- A. Query rates from coding staff
- B. Coding productivity statistics
- C. CC and MCC capture rates
- D. Physician satisfaction surveys
Answer: C
Explanation:
Explanation
The factor that should be examined when developing documentation integrity projects is CC and MCC capture rates. CC stands for complication or comorbidity, and MCC stands for major complication or comorbidity.
These are secondary diagnoses that affect the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality measures of the hospital. CC and MCC capture rates measure how well the clinical documentation reflects the presence and impact of these conditions on the patient's care. Examining CC and MCC capture rates can help to identify documentation improvement opportunities, goals, strategies, and outcomes4 References: 1:
https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 4:
https://my.ahima.org/store/product?id=67077
NEW QUESTION # 64
A hospital is conducting a documentation integrity project for the purpose of reducing indiscriminate use of electronic copy and paste of patient information in records by physicians. Which data should be used to quantify the extent of the problem?
- A. Incidence of redundancies in physician notes in a sample of hospital admissions
- B. Results of a survey of physicians that asks about documentation practices
- C. Number of coder queries regarding inconsistent physician record documentation
- D. Percent of insurance billings denied due to lack of record documentation
Answer: A
Explanation:
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a documentation integrity project is a systematic process of identifying, analyzing, and improving the quality and accuracy of clinical documentation in the health record1. A documentation integrity project may have various purposes, such as enhancing patient safety, improving coding and reimbursement, or complying with regulatory standards1. One of the common issues that may affect the quality and accuracy of clinical documentation is the indiscriminate use of electronic copy and paste of patient information in records by physicians2. Copy and paste is a function that allows physicians to duplicate existing text in the record and paste it in a new destination, which may save time and effort, but also may introduce errors, inconsistencies, or redundancies in the documentation2. Therefore, to quantify the extent of the problem of copy and paste, the data that should be used is the incidence of redundancies in physician notes in a sample of hospital admissions. Redundancies are repeated or unnecessary information that may clutter the record and impair its readability and reliability3. By measuring the frequency and types of redundancies in physician notes, the hospital can assess the impact of copy and paste on the documentation quality and identify areas for improvement. The other options are not correct because they do not directly measure the problem of copy and paste. The percent of insurance billings denied due to lack of record documentation may reflect other issues besides copy and paste, such as incomplete or inaccurate documentation, coding errors, or payer policies4. The number of coder queries regarding inconsistent physician record documentation may indicate the presence of copy and paste, but it may also depend on other factors such as coder knowledge, query guidelines, or query response rate. The results of a survey of physicians that asks about documentation practices may provide some insight into the perceptions and attitudes of physicians regarding copy and paste, but it may not reflect the actual extent or impact of the problem on the documentation quality.
CDIP Exam Preparation Guide - AHIMA
Auditing Copy and Paste - AHIMA
Copy/Paste: Prevalence, Problems, and Best Practices - AHIMA
Documentation Denials: How to Avoid Them - AAPC
[Q&A: Querying for clinical validation | ACDIS]
NEW QUESTION # 65
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