CDIP Technology and Health Information Systems 2 — Questions and Answers
Question 1: Which data element within an EHR is the CDI specialist MOST likely to use as a trigger for initiating a record review?
- Dietary preferences documented by nursing
- Laboratory values indicating organ dysfunction such as elevated creatinine or lactic acid (Correct answer)
- Patient's primary insurance plan type
- Scheduled therapy appointments
Correct answer: Laboratory values indicating organ dysfunction such as elevated creatinine or lactic acid
Abnormal lab values are objective clinical indicators that may suggest an unspecified or underdocumented condition requiring CDI clarification.
Question 2: What is the role of an encoder in the CDI and coding workflow?
- It directly queries physicians on behalf of CDI specialists
- It translates clinical diagnoses and procedures into ICD-10-CM/PCS codes and calculates DRG assignments (Correct answer)
- It schedules concurrent review assignments for CDI staff
- It transmits insurance eligibility data to payers
Correct answer: It translates clinical diagnoses and procedures into ICD-10-CM/PCS codes and calculates DRG assignments
An encoder is a software tool that guides coders and CDI specialists through ICD-10-CM/PCS code selection and calculates the resulting DRG and relative weight.
Question 3: Which health information technology standard BEST ensures that data exchanged between a hospital EHR and an external CDI analytics platform is structured and readable?
- HL7 FHIR (Fast Healthcare Interoperability Resources) (Correct answer)
- DICOM imaging protocol
- HIPAA Privacy Rule
- OSHA occupational safety regulations
Correct answer: HL7 FHIR (Fast Healthcare Interoperability Resources)
HL7 FHIR is the current standard for exchanging healthcare information electronically in a structured, machine-readable format between different health IT systems.
Question 4: A CDI program wants to use predictive analytics to identify patients at high risk for a secondary diagnosis. Which data source would provide the MOST actionable input?
- Patient billing address
- Aggregated clinical indicators such as vital signs trends, medication orders, and lab results fed into a risk-stratification model (Correct answer)
- Number of family visitors per day
- Physician board certification year
Correct answer: Aggregated clinical indicators such as vital signs trends, medication orders, and lab results fed into a risk-stratification model
Predictive models trained on structured clinical data — vitals, labs, medications — can surface high-probability secondary diagnoses before discharge, guiding proactive CDI review.
Question 5: How does computer-assisted coding (CAC) technology support the CDI workflow?
- It permanently assigns final codes without coder or CDI review
- It suggests diagnosis and procedure codes from clinical documentation, which CDI specialists and coders validate and confirm (Correct answer)
- It replaces the need for ICD-10 training
- It bills payers directly without a coding review step
Correct answer: It suggests diagnosis and procedure codes from clinical documentation, which CDI specialists and coders validate and confirm
CAC uses NLP to propose codes from clinical text, but human review by coders and CDI specialists is always required to validate accuracy and compliance.
Question 6: Which approach BEST protects the integrity of CDI query data stored within an EHR system?
- Allowing all clinical staff unrestricted access to query records
- Implementing role-based access controls so only authorized CDI staff and physicians can create, view, or respond to queries (Correct answer)
- Storing queries in a separate paper file outside the EHR
- Deleting queries once the physician responds
Correct answer: Implementing role-based access controls so only authorized CDI staff and physicians can create, view, or respond to queries
Role-based access controls ensure that only authorized individuals can interact with query records, protecting data integrity, privacy, and compliance with HIPAA requirements.
Question 7: When evaluating CDI software for a hospital, which capability should be weighted MOST heavily from a compliance perspective?
- Vendor's social media presence
- The system's ability to generate compliant, non-leading query templates aligned with AHIMA/ACDIS guidelines (Correct answer)
- Integration with food service ordering
- Built-in physician scheduling module
Correct answer: The system's ability to generate compliant, non-leading query templates aligned with AHIMA/ACDIS guidelines
Query compliance is the cornerstone of ethical CDI practice; software that enforces compliant template standards mitigates risk of fraudulent documentation practices.
CDIP Technology and Health Information Systems 2
Which data element within an EHR is the CDI specialist MOST likely to use as a trigger for initiating a record review?