Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?
Correct Answer: A
Explanation Inconsistent clinically relevant queries may make physicians lose respect for CDI efforts and disengage because they may perceive them as irrelevant, redundant, or contradictory. Clinically relevant queries are those that affect the quality of care, patient safety, severity of illness, risk of mortality, or reimbursement. Inconsistent queries may result from lack of standardization, conflicting guidelines, poor communication, or lack of clinical validation. To avoid inconsistency, CDI practitioners should follow best practices such as using evidence-based criteria, adhering to query policies and procedures, collaborating with coding and quality staff, and seeking feedback from physicians and physician advisors 2. References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 136 3 2: Proactive CDI: Tackling the Problem of Physician Engagement 4
Question 42
Based on the flowchart below, at what point might the clinical documentation integrity practitioner (CDIP) enlist the help of the physician advisor/champion?
Correct Answer: A
Question 43
A hospital administrator has hired a clinical documentation integrity (CDI) firm to improve its revenue objectives. The physicians object to this action. How should the firm collaborate with physicians to overcome their objections?
Correct Answer: D
Explanation A physician advisor/champion is a physician leader who supports and advocates for the CDI program and its objectives. A physician advisor/champion can help overcome the objections of other physicians by providing education, feedback, guidance, and mentorship on documentation best practices and their impact on revenue, quality, and patient care. A physician advisor/champion can also act as a liaison between the CDI firm and the medical staff, resolve conflicts or discrepancies in documentation, and foster a culture of collaboration and improvement. Physicians are more likely to trust and engage with their peers who understand their clinical perspective and challenges, rather than an external CDI firm that may be perceived as intrusive or disruptive. A:Create a vision statement that outlines the project objectives. This is not sufficient to collaborate with physicians and overcome their objections. A vision statement is a general statement that describes the desired outcome of the project, but it does not address the specific concerns or questions that physicians may have about the CDI firm's role, methods, or benefits. B:Communicate the benefits of the CDI firm about the project. This is not enough to collaborate with physicians and overcome their objections. Communicating the benefits of the CDI firm may be informative, but it may not be persuasive or credible if it comes from the CDI firm itself, without any endorsement or support from a physician leader within the organization. C: Hire a consultant to communicate the benefits to the physicians. This is not a good way to collaborate with physicians and overcome their objections. Hiring a consultant may add another layer of complexity and cost to the project, and it may not improve the trust or relationship between the CDI firm and the physicians. A consultant may also lack the clinical expertise or authority to influence the physicians' behavior or attitude. References: CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Q&A: Defining roles for physician advisor/champion | ACDIS Q&A: The Role of the Physician Advisor in CDI | ACDIS The Role of a Physician Advisor - UASI Solutions PA/NP in Physician Champion / Advisor Role - ACDIS Forums
Question 44
A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician's documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit. Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD. Discharge diagnoses: 1. Pneumonia 2. COPD 3. Current smoker What is the correct diagnostic related group assignment?
Correct Answer: A
Explanation According to the ICD-10-CM/PCS MS-DRG Definitions Manual, DRG 190 is assigned for patients with a principal diagnosis of chronic obstructive pulmonary disease (COPD) and a major complication or comorbidity (MCC)1. Pneumonia is considered an MCC for this DRG2. Therefore, the patient in this case meets the criteria for DRG 190. The other options are incorrect because they do not match the principal diagnosis or the MCC of the patient. ICD-10-CM/PCS MS-DRG Definitions Manual ICD-10-CM/PCS MS-DRG v38.0 Definitions Manual - MDC 4: Diseases and Disorders of the Respiratory System
Question 45
What is the term used when a patient is entered in the Master Patient Index (MPI) multiple times, in different ways, resulting in multiple medical record numbers?
Correct Answer: D
Explanation The term used when a patient is entered in the MPI multiple times, in different ways, resulting in multiple medical record numbers is overlap. An overlap occurs when a person has more than one medical record number within an integrated delivery network or enterprise, and may cause problems such as incomplete or inaccurate patient information, duplicate testing or treatment, billing errors, or patient safety issues. An overlap may be caused by data entry errors, system conversions, mergers or acquisitions, or lack of standardization. Regular audits of the MPI database must be done to identify and resolve any overlaps and ensure data quality and integrity. References: CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) Master patient index - Clinfowiki1
