RHIT Clinical Documentation Improvement

Question 1

What is the primary goal of a Clinical Documentation Improvement (CDI) program?

Accepted Answer

Ensure physician documentation accurately reflects the severity of illness and quality of care

Answer

Reduce the number of patient admissions

Answer

Eliminate all paper records from the health system

Answer

Increase the number of coded diagnoses per encounter

Question 2

A CDI specialist reviews a record and notices a patient was treated for 'respiratory failure' but only 'pneumonia' is documented. What should the CDI specialist do?

Accepted Answer

Submit a query to the physician to clarify the diagnosis

Answer

Code respiratory failure without physician documentation

Answer

Ignore the discrepancy and code only what is documented

Answer

Change the documentation to reflect respiratory failure

Question 3

Which of the following is an example of a compliant physician query format?

Accepted Answer

A query presenting multiple clinically supported options including 'other' and 'undetermined'

Answer

A leading query that suggests a specific diagnosis

Answer

A verbal-only query with no documentation

Answer

A query sent to a non-treating provider

Question 4

What does the term 'principal diagnosis' mean in the context of inpatient coding?

Accepted Answer

The condition established after study to be chiefly responsible for the admission

Answer

The condition that caused the patient to seek care initially

Answer

The most expensive condition to treat

Answer

The first diagnosis listed in the problem list

Question 5

Which organization publishes the Official Guidelines for Coding and Reporting used by CDI specialists?

Accepted Answer

Centers for Medicare & Medicaid Services (CMS) and National Center for Health Statistics (NCHS)

Answer

American Health Information Management Association (AHIMA)

Answer

The Joint Commission (TJC)

Answer

American Medical Association (AMA)

Question 6

A patient's record shows a blood glucose of 450 mg/dL and the physician documents 'hyperglycemia.' A CDI specialist queries for diabetes mellitus with hyperglycemia. This query is appropriate because:

Accepted Answer

Clinical indicators in the record support a more specific diagnosis

Answer

The coder wants to increase the DRG weight

Answer

Hyperglycemia is always synonymous with diabetes

Answer

The physician must document diabetes for billing purposes