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AHIMA Certification
CDIP Exam
AHIMA.CDIP.v2024-04-28.q49 Dumps

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Question 46

Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

A.Chief Medical Officer
B.Compliance Officer
C.CDI practitioner
D.Chief Financial Officer

Correct Answer: A

Explanation
The clinical documentation integrity (CDI) manager should consult the Chief Medical Officer when developing query policy and procedures because the Chief Medical Officer is responsible for overseeing the quality and safety of patient care, ensuring compliance with regulatory and accreditation standards, and providing leadership and guidance to the medical staff. The Chief Medical Officer can help to establish the goals, scope, and authority of the CDI program, as well as to support the query process and promote provider education and engagement. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2

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Question 47

The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?

A.Have CDI manager teaming with coding supervisor to monitor physician responses
B.Require physicians to document responses in charts
C.Permit CDI practitioners to document physician responses in the charts
D.Allow physician to respond via e-mail

Correct Answer: B

Explanation
According to the AHIMA/ACDIS Query Practice Brief, one of the best practices for a compliant query process is to require physicians to document their responses to queries in the health record1. This ensures that the documentation is consistent, accurate, and complete, and that the query and response are part of the permanent record. Verbal responses are not acceptable, as they do not provide a clear audit trail and may lead to errors or discrepancies in coding and billing1. Therefore, the CDI manager should educate the physicians on the importance of documenting their responses in the charts and monitor their compliance. The other options are not recommended, as they may compromise the integrity of the documentation or violate the query guidelines1. References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

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Question 48

A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?

A.Look for wound care documentation
B.Read the nursing admission notes
C.Query the attending provider
D.Review the history and physical

Correct Answer: D

Explanation
The first step that a clinical documentation integrity practitioner (CDIP) should take to determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary is to review the history and physical (H&P) because it is the initial source of information about the patient's condition at the time of admission. The H&P should include a comprehensive physical examination that covers all body systems, including the skin. If the H&P documents the presence of a stage IV sacral decubitus ulcer, then the POA status is "yes". If the H&P does not mention the ulcer, then the CDIP should look for other sources of documentation, such as wound care notes, nursing notes, or progress notes, to see if the ulcer was identified or treated during the hospital stay. If there is no clear evidence of when the ulcer developed, then the CDIP should query the attending provider to clarify the POA status. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Present on Admission Reporting Guidelines3

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Question 49

Which physician would best benefit from additional education for unanswered queries?

A.Dr. A
B.Dr. B
C.Dr. C
D.Dr. D

Correct Answer: D

Explanation
According to the Documentation Integrity Practitioner (CDIP) study guide, the physician with the highest number of unanswered queries would benefit from additional education. In this case, Dr. D has the highest number of unanswered queries with 9. Unanswered queries may indicate a lack of understanding, engagement, or compliance with the query process, which may affect the quality and accuracy of clinical documentation and coding1. Therefore, Dr. D would best benefit from additional education for unanswered queries, such as the importance of timely and appropriate query responses, the impact of queries on severity of illness, risk of mortality, and reimbursement, and the best practices for a compliant query practice2. References:
Q&A: What to do with unanswered queries | ACDIS
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

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