AHIMA-CDIP MCQs
AHIMA-CDIP TestPrep AHIMA-CDIP Study Guide AHIMA-CDIP Practice Test AHIMA-CDIP Exam Questions
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A patient undergoes a coronary artery bypass graft (CABG) using a saphenous vein graft. The operative report notes three coronary arteries bypassed. The provider documents "CABG" without details. The CDIP queries for clarification, and the provider confirms "three-vessel CABG with saphenous vein graft." What is the correct ICD-10-PCS code?
021109W - Bypass coronary artery, one artery, from coronary artery with autologous venous tissue, open approach
021209W - Bypass coronary artery, two arteries, from coronary artery with autologous venous tissue, open approach
021409W - Bypass coronary artery, four or more arteries, from coronary artery with autologous venous tissue, open approach
021309W - Bypass coronary artery, three arteries, from coronary artery with autologous venous tissue, open approach
Answer: D
Explanation: The query confirms a three-vessel CABG with a saphenous vein graft, making 021309W the correct ICD-10-PCS code for bypassing three coronary arteries with autologous venous tissue, open approach.
A patient with a history of COPD is admitted with respiratory distress. Labs show pH 7.32, pCO2 55 mmHg, and HCO3 28 mEq/L. The physician documents "COPD exacerbation." The CDIP identifies a gap in documentation regarding the acuity of respiratory failure. Which query best addresses this gap?
Was the respiratory distress present on admission?
Is the COPD exacerbation related to pneumonia?
Please document "acute on chronic respiratory failure" in the next note.
Can you clarify if the respiratory distress is due to acute respiratory failure based on pH 7.32 and pCO2 55 mmHg?
Answer: D
Explanation: The query "Can you clarify if the respiratory distress is due to acute respiratory failure based on pH 7.32 and pCO2 55 mmHg?" is compliant as it uses clinical indicators (abnormal arterial blood gas values) to prompt clarification without leading to a specific diagnosis. "Is the COPD exacerbation related to pneumonia?" introduces a condition not supported by the scenario. "Please document 'acute on chronic respiratory failure' in the next note" is leading and non-compliant. "Was the
respiratory distress present on admission?" does not address the acuity gap.
During a weekly CDI team meeting, a CDIP identifies that a physician consistently fails to respond to concurrent queries regarding the acuity of chronic systolic heart failure exacerbation. According to best practice and chain of command, what should the CDIP do next if the physician does not answer the query after two attempts?
Escalate the issue to the CDI department manager for intervention
Document the physician's non-response and close the query
Directly contact the physician's department chair for a response
Notify coding staff to assign the most conservative code
Answer: A
Explanation: Recognizing the chain of command for unresolved queries involves escalating the issue to the CDI manager or higher leadership when physicians do not respond after reasonable attempts. Directly contacting department chairs may be premature if appropriate escalation is established. Documenting
non-response without escalation risks incomplete or inaccurate documentation. Coders assigning conservative codes without physician clarification could affect reimbursement accuracy.
A 65-year-old patient is admitted with chest pain and suspected myocardial infarction. The physician documents "chest pain, rule out MI" but includes no further details. The CDI practitioner needs to clarify the diagnosis to ensure accurate coding and reimbursement. Which query format complies with AHIMA's best practices for a compliant, non-leading query?
Please document "acute myocardial infarction" if applicable.
Is the chest pain consistent with acute myocardial infarction?
Please confirm if the diagnosis is acute myocardial infarction.
Could you clarify if the chest pain is due to acute myocardial infarction or another cause?
Answer: D
Explanation: According to AHIMA practice briefs, a compliant query must be non-leading and provide multiple reasonable options for the provider to consider. "Could you clarify if the chest pain is due to acute myocardial infarction or another cause?" allows the provider to specify the diagnosis without suggesting a specific condition, aligning with best practices. "Is the chest pain consistent with acute myocardial infarction?" and "Please confirm if the diagnosis is acute myocardial infarction" are leading as they focus solely on myocardial infarction. "Please document 'acute myocardial infarction' if applicable" is overly directive and non-compliant.
A patient's discharge summary states ???status post small bowel obstruction??? but no current obstruction is documented during admission. How should the CDI practitioner handle this?
Remove bowel obstruction diagnosis from coding.
Accept ???status post??? as current diagnosis.
Query the provider to clarify if the bowel obstruction is active or resolved.
Query for history of hernia instead.
Answer: C
Explanation: ???Status post??? indicates resolved condition; querying clarifies active status for coding. Accepting as current would be inaccurate; removing diagnosis without provider input is inappropriate, and querying unrelated diagnosis is not helpful.
A patient is admitted with a principal diagnosis of sepsis due to E- coli (ICD-10-CM: A41.51). The coder assigns DRG 871 (Sepsis with MCC). The CDI practitioner reviews the record and notes a serum lactate of 4.2 mmol/L (reference <2.0 mmol/L) and hypotension requiring vasopressors. The physician does not document severe sepsis. What should the CDI practitioner do to ensure accurate DRG assignment?
Accept the current DRG as it reflects the clinical picture.
Query the physician to clarify if severe sepsis is present based on lactate and hypotension.
Request the coder to change the DRG to 870 (Sepsis with organ dysfunction).
Update the record to include severe sepsis without a query.
Answer: B
Explanation: Querying the physician to clarify if severe sepsis is present based on lactate (4.2 mmol/L) and hypotension requiring vasopressors is necessary to ensure accurate DRG assignment. These clinical indicators suggest severe sepsis, which could impact the DRG (e.g., ensuring the MCC is captured). Accepting the current DRG without clarification risks undercoding. Requesting the coder to change the DRG without a query is non-compliant, as coders cannot interpret clinical indicators without physician documentation. Updating the record without a query violates AHIMA guidelines, as CDI practitioners cannot add diagnoses.
A CDI manager is promoting CDI efforts to hospital administration by presenting a project on improving documentation for pneumonia cases. The project tracks 50 patients with initial DRG 195 (simple pneumonia, RW 0.7) and post-CDI intervention DRG 193 (pneumonia with MCC, RW 1.2). The average reimbursement increase is $3,000 per case. Which strategy best demonstrates the project's value to administration?
Highlight the increase in physician query response time
Present the reimbursement increase due to DRG shifts
Report the reduction in coding errors
Show the decrease in patient readmissions
Answer: B
Explanation: Presenting the reimbursement increase due to DRG shifts from simple pneumonia (RW 0.7) to pneumonia with MCC (RW 1.2), with a $3,000 per case increase, directly demonstrates financial value to administration. Physician query response time, coding error reduction, and readmission decreases are important but less directly tied to financial ROI.
A CDI practitioner reviews a chart with a patient admitted for chest pain and elevated troponin of 0.8 ng/mL. The physician documented "chest pain, rule out MI," but no query was issued. The CDI dashboard shows a 20% missed opportunity rate for acute MI queries. What is the most compliant action to improve this metric?
Implement a policy requiring queries for all elevated troponin cases
Issue a retrospective query for acute MI based on troponin levels
Perform a quality audit to identify missed MI query opportunities
Train CDI staff to prioritize troponin-based queries
Answer: C
Explanation: A 20% missed opportunity rate for acute MI queries suggests systemic issues in query practices. Perform a quality audit to identify missed MI query opportunities is the most compliant approach to analyze why queries are missed and improve processes. Implement a policy requiring queries for all elevated troponin cases is non-compliant, as queries must be based on clinical indicators, not automatic triggers. Issue a retrospective query for acute MI based on troponin levels may be appropriate but does not address the broader metric issue. Train CDI staff to prioritize troponin-based queries is too narrow without audit data.
A patient with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The provider documents ???COPD exacerbation??? but does not specify severity or presence of respiratory failure. ABGs show pH 7.30 and pCO2 58 mmHg. How should the CDI practitioner proceed?
Query provider for documentation of COPD exacerbation severity including any respiratory failure indicators
Accept general COPD exacerbation diagnosis without severity details
Assign respiratory failure based on ABG results without provider input
Ignore severity documentation as it does not affect coding
Answer: A
Explanation: Queries that ask providers to specify severity, including respiratory failure, improve documentation quality and coding accuracy. ABG results provide clinical data supporting severity but require provider confirmation for documentation integrity. Accepting vague documentation or assigning codes without provider input is inadequate.
A patient is admitted with a potassium level of 6.5 mEq/L (normal 3.5-5.0 mEq/L) and EKG changes. The physician documents "electrolyte abnormality." To ensure accurate coding, what is the most compliant query?
Is the electrolyte abnormality related to renal failure?
Does the patient have hyperkalemia or another condition?
Can you clarify if the electrolyte abnormality is hyperkalemia?
Please document the electrolyte abnormality as hyperkalemia.
Answer: C
Explanation: "Can you clarify if the electrolyte abnormality is hyperkalemia?" is compliant, as it uses clinical indicators (potassium 6.5 mEq/L, EKG changes) and allows the provider to confirm or clarify without leading. "Does the patient have hyperkalemia or another condition?" is less specific. "Is the electrolyte abnormality related to renal failure?" is irrelevant to the primary diagnosis. "Please document the electrolyte abnormality as hyperkalemia" is non-compliant.
During query development, what should a CDIP avoid?
Providing clinical indicators to support clarification.
Phrasing queries that lead the provider to a specific diagnosis or outcome.
Referencing relevant documentation in the query.
Including a response option of "No additional information available."
Answer: B
Explanation: Queries must be non-leading. The others represent correct compliant practices.
A 58-year-old male is admitted for acute pancreatitis. The physician documents "acute pancreatitis, likely alcohol-related." Labs show lipase 1200 U/L (reference <160 U/L) and creatinine 2.5 mg/dL (reference 0.6-1.2 mg/dL). The CDI practitioner notes the elevated creatinine. Which query best clarifies the documentation for accurate coding?
Can you confirm if the pancreatitis is uncomplicated?
Does the creatinine of 2.5 mg/dL indicate acute kidney injury?
Is the pancreatitis due to gallstones or alcohol?
Please document the etiology of the pancreatitis.
Answer: B
Explanation: The query "Does the creatinine of 2.5 mg/dL indicate acute kidney injury?" is most appropriate as it addresses the elevated creatinine, a clinical indicator of potential acute kidney injury (AKI), which could qualify as a CC and impact the DRG. It is non-leading and evidence-based. "Can you confirm if the pancreatitis is uncomplicated?" ignores the creatinine elevation. "Is the pancreatitis due to gallstones or alcohol?" focuses on etiology without addressing the potential AKI. "Please document the etiology of the pancreatitis" is too broad and misses the opportunity to capture the CC.
A CDI team collaborates with a physician champion to improve documentation for acute kidney injury (AKI). Which initiative best supports AHIMA's leadership development goals?
Automate AKI alerts in the EHR
Mandate AKI training for CDI staff only
Develop an AKI documentation tip sheet with physician input
Require daily AKI audits by HIM
Answer: C
Explanation: AHIMA emphasizes physician collaboration in CDI initiatives. Developing an AKI documentation tip sheet with physician input fosters engagement and aligns with leadership goals. "Automate AKI alerts in the EHR" lacks physician collaboration. "Mandate AKI training for CDI staff only" excludes physicians. "Require daily AKI audits by HIM" is not collaborative.
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