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

CDI programs ensure that physician documentation accurately and completely reflects the patient's clinical status to support accurate coding, reimbursement, and quality reporting.

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

CDI specialists submit physician queries to clarify ambiguous or incomplete documentation rather than assuming or altering records.

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

Compliant queries are non-leading, present multiple supported options, and include clinical indicators to guide physician response.

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 principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the hospital admission.

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

CMS and NCHS jointly publish the ICD-10-CM Official Guidelines for Coding and Reporting, which govern diagnosis code assignment.

RHIT - Registered Health Information Technician Practice Test

RHIT - Registered Health Information Technician Practice Test

RHIT Clinical Documentation Improvement