Tracking denials within the clinical documentation integrity program is important to

1. A. determine coding inaccuracies and educate as necessary
2. B. file a timely appeal if the medical center disagrees with the RAC findings
3. C. identify documentation improvement opportunities and educate as necessary
4. D. confirm reimbursement was appropriate

Correct Answer: C
Tracking denials within the clinical documentation integrity program is important to identify documentation improvement opportunities and educate as necessary because it helps to analyze the root causes of denials, improve the quality and specificity of clinical documentation, and reduce the risk of future denials. Denials can also provide feedback on the effectiveness of the CDI program and the areas that need more attention or intervention. (CDIP Exam Preparation Guide)
References:
✑ CDIP Exam Content Outline1
✑ CDIP Exam Preparation Guide2

A patient was admitted with complaints of confusion, weakness, and slurred speech. A CT of the head and MRI were performed and resulted in normal findings. Daily aspirin was administered and a speech therapy evaluation was conducted. The final diagnosis on discharge was transient ischemic attack, and cerebrovascular disease
was ruled out. What is the correct diagnostic related group assignment?

1. A. 093 Other Disorders of Nervous System without CC/MCC
2. B. 948 Signs and Symptoms without MCC
3. C. 069 Transient Ischemia
4. D. 066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC

Correct Answer: C
Transient ischemic attack (TIA) is a neurological event with the signs and symptoms of a stroke, but which go away within a short period of time. TIA is assigned to DRG 069, which is a medical DRG. Cerebrovascular disease was ruled out, so it cannot be coded as a secondary diagnosis. The other options are incorrect because they do not reflect the principal diagnosis of TIA.

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?

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

Correct Answer: D
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

Which of the following is an appropriate first step to address physicians with low query response rates?

1. A. An educational session between the clinical documentation integrity practitioner (CDIP) and physician
2. B. The medical staff review the physician's noncompliance to consider sanctions
3. C. The physician receives a suspension until query responses are improved
4. D. A meeting between the physician advisor/champion and the noncompliant physician

Correct Answer: A
An appropriate first step to address physicians with low query response rates is an educational session between the clinical documentation integrity practitioner (CDIP) and physician because it provides an opportunity to explain the purpose and benefits of the query process, to identify and address any barriers or challenges to responding, and to offer feedback and guidance on how to improve query response rates. An educational session can also help to build rapport and trust between the CDIP and the physician, and to demonstrate respect and professionalism. (CDIP Exam Preparation Guide) References:
✑ CDIP Exam Content Outline1
✑ CDIP Exam Preparation Guide2
✑ Understanding CDI Metrics3

The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate. What might this indicate to the CDI manager?

1. A. The program is successful because documentation has improved
2. B. The loss of a large volume of patients has impacted workflow
3. C. CDI staff need education on identifying query opportunities
4. D. The decrease in hospital census has caused a lack of query opportunities

Correct Answer: C
A drastic drop in the physician query rate might indicate to the CDI manager that the CDI staff need education on identifying query opportunities. The physician query rate is a metric that measures the percentage of records that have at least one query sent by the CDI staff to clarify or improve the documentation. A high query rate may reflect a high level of documentation quality issues or a high level of CDI staff vigilance and expertise. A low query rate may reflect a low level of documentation quality issues or a low level of CDI staff awareness and competence 2. Therefore, a drastic drop in the query rate could suggest that the CDI staff are missing some query opportunities or are not following the query policies and procedures. The CDI manager should investigate the reasons for the drop and provide education and feedback to the CDI staff on how to identify and address query opportunities effectively and compliantly 3.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: Understanding CDI
Metrics - AHIMA 2 3: The Natural History of CDI Programs: A Metric-Based Model 5