AHIMA AHIMA Clinical Documentation Improvement 1

Question 1

What is the primary goal of a Clinical Documentation Improvement (CDI) program in a US hospital?

Accepted Answer

Ensure clinical documentation accurately reflects patient severity and resource utilization

Answer

Reduce nursing documentation time

Answer

Increase the number of coded diagnoses per chart

Answer

Speed up the discharge process

Question 2

Which query type asks a physician to clarify documentation without suggesting a specific diagnosis?

Accepted Answer

Non-leading query

Answer

Leading query

Answer

Closed query

Answer

Retrospective query

Question 3

What does the term 'principal diagnosis' mean in the context of US inpatient coding under UHDDS guidelines?

Accepted Answer

The condition established after study to be chiefly responsible for the admission

Answer

The most severe diagnosis the patient has

Answer

The first diagnosis listed by the physician

Answer

The diagnosis that generated the most charges

Question 4

Which condition must be documented by the physician for a CDI specialist to query for 'malnutrition' to affect MS-DRG assignment?

Accepted Answer

Clinical indicators such as poor intake, weight loss, or muscle wasting documented alongside a clinical diagnosis

Answer

Low albumin level only

Answer

BMI below 18.5

Answer

Any mention of dietary restrictions

Question 5

What is a 'concurrent' CDI review?

Accepted Answer

Review performed while the patient is still admitted

Answer

Review performed after the patient is discharged

Answer

Review performed only on surgical cases

Answer

Review performed by an external auditor

Question 6

Under ICD-10-CM/PCS guidelines, when is it appropriate to code a condition as 'present on admission' (POA)?

Accepted Answer

When the condition exists at the time the order for inpatient admission occurs

Answer

When the condition develops within 24 hours of admission

Answer

When the condition is documented on the face sheet

Answer

When the attending physician designates it as pre-existing