RHIT Clinical Documentation Improvement 2

Question 1

Which metric is commonly used to measure the effectiveness of a CDI program?

Accepted Answer

Case Mix Index (CMI)

Answer

The Case Mix Index reflects the average DRG weight of a facility's patients and is a key indicator of CDI program impact on reimbursement accuracy.

Question 2

What is a 'present on admission' (POA) indicator used for?

Accepted Answer

To identify diagnoses that existed before the hospital stay for quality and payment purposes

Answer

POA indicators identify whether a diagnosis was present at the time of inpatient admission, affecting hospital-acquired condition (HAC) reporting and reimbursement.

Question 3

Which of the following documentation practices supports accurate MS-DRG assignment?

Accepted Answer

Clearly documenting complications and comorbidities (CCs) and major CCs (MCCs)

Answer

Documenting CCs and MCCs is critical because they affect MS-DRG grouping, which determines inpatient reimbursement under Medicare.

Question 4

A CDI specialist finds that a physician documented 'sepsis' but clinical indicators suggest 'severe sepsis.' What is the CDI specialist's role?

Accepted Answer

Query the physician to confirm whether severe sepsis criteria are met

Answer

CDI specialists should query physicians when clinical evidence suggests a more specific or serious condition than what is currently documented.

Question 5

Which type of CDI query is sent while the patient is still admitted?

Accepted Answer

Concurrent query

Answer

Concurrent queries are issued during the patient's stay, allowing physicians to update documentation before discharge, which is preferred for accuracy.

RHIT - Registered Health Information Technician Practice Test

RHIT - Registered Health Information Technician Practice Test

RHIT Clinical Documentation Improvement 2