AHIMA AHIMA Clinical Documentation Improvement 3

Question 1

What is 'query compliance' in CDI practice?

Accepted Answer

Adherence to established guidelines ensuring queries are non-leading, clinically supported, and properly documented

Answer

The rate at which physicians respond to queries

Answer

The percentage of queries that result in a higher MS-DRG

Answer

The number of queries issued per 100 discharges

Question 2

Under UHDDS guidelines, which diagnoses should be reported as 'additional diagnoses' for inpatient encounters?

Accepted Answer

Conditions that are clinically evaluated, treated, or affect the management of the patient during the stay

Answer

Only diagnoses confirmed by lab results

Answer

All diagnoses mentioned anywhere in the record

Answer

Only diagnoses present on admission

Question 3

What is the role of the Case Mix Index (CMI) trend in assessing CDI program effectiveness?

Accepted Answer

An increasing CMI after CDI implementation may suggest improved documentation capture of patient complexity

Answer

A rising CMI always indicates fraud

Answer

CMI is unrelated to CDI outcomes

Answer

CMI measures only surgical case complexity

Question 4

Which ICD-10-CM coding guideline instructs coders to code conditions to the 'highest degree of certainty' for inpatient settings?

Accepted Answer

The uncertain diagnosis guideline, allowing coding of conditions documented as 'possible' or 'probable' at discharge

Answer

The UHDDS rule

Answer

The present on admission guideline

Answer

The principal diagnosis selection rule

Question 5

What is 'severity of illness' (SOI) in the context of clinical documentation and reimbursement?

Accepted Answer

A measure of the extent of physiologic decompensation or organ system loss of function

Answer

A Medicare billing modifier

Answer

The patient's pain scale score

Answer

The number of diagnoses assigned to a case

Question 6

Which CMS program penalizes hospitals for excess readmissions and relies on accurate clinical documentation?

Accepted Answer

Hospital Readmissions Reduction Program (HRRP)

Answer

Medicare Shared Savings Program

Answer

Bundled Payments for Care Improvement (BPCI)

Answer

Merit-based Incentive Payment System (MIPS)