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| Section | Weight | Objectives |
|---|---|---|
| Record Review & Document Clarification | 24–28% | - POA, HAC, SOI, ROM clarification - Identify documentation gaps and specificity issues - Ethical provider query development - Compliance with query standards - Query tracking and follow-up |
| CDI Metrics & Statistics | 14–18% | - DRG comparison and denial analysis - Quality audits and compliance monitoring - Query response and volume tracking - Benchmarking and reporting |
| Clinical Coding Practice | 22–26% | - DRG, CPT, and HCPCS code assignment - ICD-10-CM/PCS coding conventions and guidelines - Coding software and reference resources - Principal and secondary diagnosis identification - Payer requirements and reimbursement models |
| Leadership | 17–22% | - Policy and procedure creation - CDI program development and promotion - Provider engagement and communication - Interdisciplinary collaboration |
| Compliance | 4–8% | - AHIMA standards and regulatory requirements - Fraud and abuse prevention - Legal and ethical documentation practices - Compliance monitoring and reporting |
| Research & Education | 11–15% | - Provider and staff education - Regulatory and guideline updates - Documentation improvement training materials - Best practice research and implementation |
1. Which of the following may result in an incomplete health record deficiency being assigned to a provider?
A) A concurrent query
B) A retrospective query
C) An outstanding query
D) A quality query
2. Which of the following clinical documentation integrity (CDI) dashboard metrics is frequently used to help evaluate the credibility of CDI practitioner queries and the success of the CDI program?
A) Provider response rate
B) CDI query rate
C) CDI agreement rate
D) Provider agreement rate
3. Reviewing and analyzing physician query content on a regular basis
A) facilitates physician data collection
B) helps to calculate query response rate
C) assists in identifying gaps in skills and knowledge
D) aids in discussion between physician and reviewer
4. A clinical documentation integrity practitioner (CDIP) is developing a plan to promote the CDI program throughout a major hospital. It is proving challenging to find support. What is a primary step for the CDIP?
A) Teach coding classes to the new physicians as needed
B) Determine primary interests of an individual or department
C) Teach nursing staff about documentation integrity
D) Determine primary interests and needs as requested
5. Which of these medical conditions would a clinical documentation integrity practitioner (CDIP) expect to be treated with Levophed?
A) Multiple sclerosis
B) Septic shock
C) Acute respiratory failure
D) Acute kidney failure
Solutions:
| Question # 1 Answer: C | Question # 2 Answer: D | Question # 3 Answer: C | Question # 4 Answer: B | Question # 5 Answer: B |
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