AHIMA AHIMA Clinical Documentation Improvement

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

CDI programs aim to ensure that clinical documentation accurately captures the patient's severity of illness and the resources used in their care.

Question 2

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

Accepted Answer

Non-leading query

Answer

A non-leading query presents clinical indicators and asks the physician to provide their clinical interpretation without suggesting an answer.

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 Uniform Hospital Discharge Data Set (UHDDS) defines the principal diagnosis as the condition established after study to be chiefly responsible for causing the admission.

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

Malnutrition requires a physician's clinical diagnosis supported by documented indicators; lab values alone are insufficient for coding purposes.

Question 5

What is a 'concurrent' CDI review?

Accepted Answer

Review performed while the patient is still admitted

Answer

Concurrent CDI review occurs while the patient is still hospitalized, allowing queries to be answered before discharge and the record is coded.

(AHIMA) American Health Information Management Association Practice Test

(AHIMA) American Health Information Management Association Practice Test

AHIMA AHIMA Clinical Documentation Improvement