CDIP Quality Improvement and Compliance 2

Question 1

A hospital's CDI team notices a pattern of sepsis cases documented without meeting Sepsis-3 criteria. Which quality improvement step should come first?

Accepted Answer

Perform a root cause analysis to identify the documentation gap

Answer

Root cause analysis identifies the underlying documentation gap before implementing corrective actions.

Question 2

Under the OIG Work Plan, which documentation pattern is most likely to trigger a focused audit of inpatient records?

Accepted Answer

High rates of principal diagnosis changes after query

Answer

High rates of principal diagnosis changes after query can signal inappropriate query practices and are an OIG audit trigger.

Question 3

A CDI specialist finds that a query was leading because it listed only DRG-favorable diagnoses. Which standard does this violate?

Accepted Answer

The ACDIS/AHIMA query practice brief

Answer

The ACDIS/AHIMA CDI query practice brief explicitly prohibits leading queries that suggest financially advantageous diagnoses.

Question 4

Which metric best measures CDI program effectiveness in improving specificity of documented diagnoses?

Accepted Answer

CC/MCC capture rate

Answer

The CC/MCC capture rate directly reflects how often complications and comorbidities are documented with sufficient specificity.

Question 5

A quality review reveals coders are querying for conditions that clearly exist in the record without physician attestation. What is the most appropriate corrective action?

Accepted Answer

Stop all queries and re-train on query indications

Answer

Queries are only appropriate when documentation is unclear, incomplete, or conflicting—not for conditions already clearly documented.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Quality Improvement and Compliance 2