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| Section | Weight | Objectives |
|---|---|---|
| CDI Metrics & Statistics | 14–18% | - Quality audits and compliance monitoring - Query response and volume tracking - DRG comparison and denial analysis - Benchmarking and reporting |
| Leadership | 17–22% | - Interdisciplinary collaboration - CDI program development and promotion - Policy and procedure creation - Provider engagement and communication |
| Research & Education | 11–15% | - Regulatory and guideline updates - Documentation improvement training materials - Best practice research and implementation - Provider and staff education |
| Record Review & Document Clarification | 24–28% | - POA, HAC, SOI, ROM clarification - Identify documentation gaps and specificity issues - Compliance with query standards - Ethical provider query development - Query tracking and follow-up |
| Clinical Coding Practice | 22–26% | - Payer requirements and reimbursement models - ICD-10-CM/PCS coding conventions and guidelines - Coding software and reference resources - Principal and secondary diagnosis identification - DRG, CPT, and HCPCS code assignment |
| Compliance | 4–8% | - Fraud and abuse prevention - AHIMA standards and regulatory requirements - Compliance monitoring and reporting - Legal and ethical documentation practices |
Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?
Correct Answer: A 🗳️
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Which of the following can be evidence of physician-hospital alignment?
Correct Answer: B 🗳️
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Which of the following is used to measure the impact of a clinical documentation integrity (CDI) program on Centers for Medicare and Medicaid Services quality performance?
Correct Answer: A 🗳️
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Which of the following is a clinical documentation element supporting a transbronchial biopsy?
Correct Answer: A 🗳️
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A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?
Correct Answer: A 🗳️
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