A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?

1. A. Any physician caring for the patient can correct inaccurate record notes
2. B. Errors are corrected by the clinician who authored the documentation
3. C. Amendments to record content must be co-signed by the attending physician
4. D. Coders can rely on the laboratory results to confirm the patient's diagnosis

Correct Answer: B
According to AHIMA, best practice for fixing a mistake in a patient health record is that errors are corrected by the clinician who authored the documentation1. The clinician who made the error should identify and correct the inaccurate information, and document the date, time, and reason for the correction1. The correction should also be made in a way that preserves the original content and does not obscure or delete it1. The other options are not correct according to AHIMA. Any physician caring for the patient cannot correct inaccurate record notes, as this may compromise the accountability and integrity of the documentation2. Amendments to record content do not need to be co-signed by the attending physician, unless required by organizational policy or state law3. Coders cannot rely on the laboratory results to confirm the patient??s diagnosis, as they should code based on the physician??s documentation and not on test results alone. References:
✑ Making Corrections in the Electronic Health Record - AHIMA
✑ Auditing Copy and Paste - AHIMA
✑ Amendments, Corrections, and Deletions in Transcribed Reports Toolkit - AHIMA
✑ [Coding from Test Results | Journal Of AHIMA]

Automated registration entries that generate erroneous patient identification—possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit—is an example of a potential breach of:

1. A. Authorship integrity
2. B. Patient identification and demographic accuracy
3. C. Documentation integrity
4. D. Auditing integrity

Correct Answer: B
Patient identification and demographic accuracy is the process of ensuring that the patient??s identity and personal information are correctly recorded and verified in the health record and other systems. A potential breach of this process could result in automated registration entries that generate erroneous patient identification, which could lead to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit2
Authorship integrity is the process of ensuring that the source and content of the health record are authentic, accurate, complete, and consistent. Documentation integrity is the process of ensuring that the health record reflects the patient??s clinical status, treatment, and outcomes. Auditing integrity is the process of ensuring that the health record is reviewed and monitored for compliance, quality, and improvement purposes2
1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 2: https://my.ahima.org/store/product?id=67077

AHIMA suggests which of the following for an organization to consider as physician response rate and agreement rate?

1. A. 80%/40%
2. B. 80%/80%
3. C. 75%/75%
4. D. 70%/50%

Correct Answer: B
AHIMA suggests that an organization should consider a physician response rate of 80% and an agreement rate of 80% as benchmarks for CDI program performance. These rates indicate the level of physician engagement and documentation accuracy in relation to CDI queries.
References: AHIMA. ??Guidelines for Achieving a Compliant Query Practice (2019 Update).?? Journal of AHIMA 90, no. 2 (February 2019): 20-29.

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?

1. A. DRG 190 Chronic Obstructive Pulmonary Disease with MCC
2. B. DRG 202 Bronchitis and Asthma with CC/MCC
3. C. DRG 204 Respiratory Signs and Symptoms
4. D. DRG 194 Simple Pneumonia and Pleurisy without CC/MCC

Correct Answer: A
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. References:
✑ 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

Proposed changes to the inpatient prospective payment system (IPPS) take effect on

1. A. October 1
2. B. January 1
3. C. July 1
4. D. April 1

Correct Answer: A
Proposed changes to the inpatient prospective payment system (IPPS) take effect on October 1 of each fiscal year (FY), which begins on October 1 and ends on September 30 of the next calendar year. The IPPS final rule is usually issued by the Centers for Medicare & Medicaid Services (CMS) around August 1 of each year, and it updates the Medicare payment policies and rates for acute care hospitals and long-term care hospitals for the upcoming FY. The effective date of the final rule is October 1, unless otherwise specified by CMS 2.
References: 1: Inpatient Prospective Payment System (IPPS) 2023 Final Rule Summary of ?? 3 2: Acute Inpatient PPS | CMS 1