AHIMA Clinical Documentation Improvement Flashcards
6 cards from real AHIMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 AHIMA Clinical Documentation Improvement flashcards as text
What is 'query compliance' in CDI practice?
Answer: Adherence to established guidelines ensuring queries are non-leading, clinically supported, and properly documented
Query compliance refers to following established industry guidelines to ensure queries are ethical, non-leading, clinically supported, and appropriately formatted.
Under UHDDS guidelines, which diagnoses should be reported as 'additional diagnoses' for inpatient encounters?
Answer: Conditions that are clinically evaluated, treated, or affect the management of the patient during the stay
UHDDS guidelines specify that additional diagnoses are conditions that require clinical evaluation, therapeutic treatment, diagnostic procedures, or affect nursing care/monitoring.
What is the role of the Case Mix Index (CMI) trend in assessing CDI program effectiveness?
Answer: An increasing CMI after CDI implementation may suggest improved documentation capture of patient complexity
An upward trend in CMI following CDI program implementation often reflects better documentation of patient severity, not necessarily sicker patients.
Which ICD-10-CM coding guideline instructs coders to code conditions to the 'highest degree of certainty' for inpatient settings?
Answer: The uncertain diagnosis guideline, allowing coding of conditions documented as 'possible' or 'probable' at discharge
For inpatient coding, ICD-10-CM guidelines allow coding of conditions documented as 'possible,' 'probable,' or 'suspected' at the time of discharge if no definitive diagnosis is established.
What is 'severity of illness' (SOI) in the context of clinical documentation and reimbursement?
Answer: A measure of the extent of physiologic decompensation or organ system loss of function
Severity of illness reflects the degree of physiologic decompensation and is used in all-patient refined DRG (APR-DRG) systems to assess resource needs.
Which CMS program penalizes hospitals for excess readmissions and relies on accurate clinical documentation?
Answer: Hospital Readmissions Reduction Program (HRRP)
The Hospital Readmissions Reduction Program penalizes hospitals with higher-than-expected readmission rates for specific conditions, making accurate documentation of comorbidities essential.