CDI Clinical Documentation Improvement 2024 Exam Quiz Study Guide with Correct Answers, Exams of Management of Health Service

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CDI Clinical Documentation Improvement

2024 Exam Quiz Study Guide with Correct

Answers 100% Pass | Graded A+

David Mungai [Date] [Course title]

CDI Clinical Documentation

Improvement 2024 Exam Quiz Study

Guide with Correct Answers 100% Pass |

Graded A+

What are the core operational components of a clinical documentation program? pg.171 - Answer>> 1. concurrent documentation review - to ID any documentation that does not meet the criteria for high-quality clinical documentation.

2. physician queries - to ask the physician who authorized the documentation to clarify the entry. All physicians should be trained on the principles of clinical documentation. What is the purpose of the documentation review? - Answer>> To identify any documentation that does not meet the criteria for high-quality clinical documentation and to ask the physician who authored the documentation to clarify the entry what is a primary reason for high-quality clinical documentation in the record? (171) - Answer>> accurate code assignment What are additional reasons? - Answer>> 1. healthcare quality report cards 2. quality of care 3. patient satisfaction 4. There is an increased need for secondary data use in public health reporting. T/F: many industry influencers count on accurate and timely documentation. (171) - Answer>> TRUE: There is an increased need for secondary data use in public health reporting. What is the name of the key resource for the physician query process that every clinician documentation improvement program should use? (171) - Answer>> AHIMA's "Guidelines for Achieving a Compliant Query Process"

there is not a valid reason for the increase, such as the addition of a new group of physicians who have not been trained on the documentation principles, the organization should consider a program reassessment by an external organization. Since a decrease in the query rate is expected, should the organization expect a decrease in workers? (173) - Answer>> No, instead they should expect a more intensive follow-up training to lower the query rate even further or to penetrate into other areas they have not down yet What is an effective training tool for the query process? (173) - Answer>> the process of observing of observing staff members and providing feedback about the query process How is the query rate calculated? (173) - Answer>> It is calculated by dividing the number of records that were queried by the total number of records reviewed If a CDI specialist reviews 100 records and 30 records contain queries, what is the query rate? (173) - Answer>> 30/100= 30 percent Which method for data collection is preferred and why? (173) - Answer>> Data collection can be manual or electronic but electronic is preferred for reliability and preservation of CDI over time. Why is establishing and tracking the query response different from establishing the review and query rates? (173) - Answer>> Because there is an additional component; the response rate depends on the physician answering the query

If the physician responds to the query, the query response rate goes__________, and if the physician does not respond, the response rate goes ____________. (173) - Answer>> up, down What factors could affect the query response of a physician? (173) - Answer>> 1. whether r not the executive team obtained the initial support of the physician

2. whether the physician attended training
3. how the physician scored on post-testing if the training included tests What other factors can influence the query response rate? (173) - Answer>> 1. the mechanics of the CDI program
4. timing of the patient's discharge How does the CDI manager calculate the query response rate? (173) - Answer>> by dividing the NUMBER OR RESPONSES by THE NUMBER OF QUERIES T/F: The time allowed for a physician to responds to a query affects the response rate. - Answer>> TRUE What is AHIMA's recommendation for how the response rate should be calculated? (174) - Answer>> AHIMA suggests considering an 80 percent physician response rate and an 80 percent agreement rate. T/F: The organization may want to consider using the same timeframe for query responses as they use for final coding. (174)

• Answer>> TRUE T/F: The physician should be informed about the timeframe in which they have to respond to a query. (174) - Answer>> TRUE

If a documentation deficiency is found during the concurrent review, what should the CDI specialist do? (176) - Answer>> 1. generate a query

2. notify the physician
3. record the query in the program database
4. record the date for follow-up review When should the follow-up review be done? (176) - Answer>> one to two days from the initial review T/F: the patient's record MUST contain clinical evidence to support any queries to the physician? (176) - Answer>> TRUE T/F: The query should clearly identify for the physician the clinical evidence in the record that is prompting the query. - Answer>> TRUE Who should receive training on the query process? (176) - Answer>> all staff members who are involved in querying physicians, as well as the physicians Queries should only be asked: (177) - Answer>> 1. If there is a valid clinical evidence that the documentation is incomplete or does not meet one of the seven criteria for high-quality clinical documentation.
5. by an individual with solid clinical knowledge
6. In an open-ended manner (physicians must document a response and cannot just responds yes or no). The exception to this rule is the present on admission (POA) query where a yes or no answer is acceptable.
7. In a non-leading manner (without pointing physicians to a specific reason response.)

5. To the individual whose documentation is in question or who is responsible for interpreting test results and other data in the patient's record. Every organization should develop a query policy and procedure that is specific to its organization and that addresses (177): - Answer>> 1. When to ask queries
6. Who asks the queries and to whom
7. The hospital's responsibility in supporting the query process
8. The physician's responsibility in responding to queries
9. Acceptable ways to respond to queries Examples of cases that require a query may include: (177-178) - Answer>> 1. Documentation of reportable conditions or procedures is conflicting, ambiguous, or otherwise incomplete
10. Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or higher specificity of an already documented condition.
11. The patient is receiving treatment for a condition the physician has not documented.
12. The physician does not document abnormal operative or procedural findings
13. It is unclear as to whether the physician ruled out a condition
14. The documentation does not identify principal diagnosis clearly What performs reviews as part of the Hospital Payment Monitoring Programs (HPMP)? (178) - Answer>> QIOs Who updates and selects QIOs? How often? Based on What? (178) - Answer>> THE CMS selects and updates them on an annual basis using historical knowledge and experience related to medically unnecessary admissions, inappropriate readmissions, and incorrect DRG coding.

WHat is bacteremia? (180) - Answer>> bacteria in the blood without an associated inflammatory response What is urosepsis? (181) - Answer>> an infection confined to the urinary system; it refers to pyuria (pus in the urine)or bacteria in the urine (not in the blood) How can every hospital prevent denying of payment on problematic diagnoses? (181) - Answer>> 1. proper physician training

2. referral of such documentation problems to peer review or the physician CDI leader
3. close review and incorporation of all HPMP communications into the physician training and query processes The _______________ __________________ performs the retrospective review in most organizations during_________ ___________________ ________________. (181) - Answer>> coding staff, the coding process What are the two processes that serves as a safety net to the CDI program and is a process that enables a coding professional to translate the physician documentation into coded date with the highest possible accuracy? (181) - Answer>> 1. Retrospective review
4. querying T/F: When there are outstanding physician queries from the concurrent review, the coding professionals can and should follow up on those queries. (181) - Answer>> TRUE

The retrospective query rate should be much _____________ than the concurrent query rate; no more than __________ percent. (181) - Answer>> lower, 10 The physician response rate for retrospective queries should be ___________ percent. (181) - Answer>> 100 Who should unite to achieve organizational CDI goals? (182) - Answer>> CDI staff and coding professionals __________________ __________________ publish clinical indicators for specific diseases, which are available from multiple sites on the Internet. (183) - Answer>> Scholarly journals What is metabolic encephalopathy? (183) - Answer>> a potentially reversible abnormality of brain function caused by processes of extracerebral origin such as acidosis, adverse reactions to medications and toxins, brain tumor, dehydration, infections, metabolic dysfunction, organ failure, or trauma The ___________________ _______________________ ______________ _________________ is one of the core operational components of every CDI program. (184) - Answer>> physician concurrent query process