CDIP Actual Exam 2025 CDIP Exam 2025
Study Guide Questions and Correct
Answers Rated A+
Which two medical professionals serve as mid-level practitioners by
supporting physicians in the delivery of care? -ANSWER-Nurse
practitioners and physician assistants
In 1982, which aspect of medical billing/reimbursement increased the
demand for accuracy and timeliness with regard to medical coding? -
ANSWER-Reimbursement was driven by codes assigned to patient
care
Which hands-on provider's documentation should the coder not use
for final coding? -ANSWER-Diagnostic radiologist
Which practitioners, along with coding professionals, are proficient at
picking up deficiencies in clinical documentation yet must focus on
giving care? -ANSWER-Nurses
Which healthcare setting requires high levels of proactivity from
management and clinical teams to ensure accurate and timely clinical
documentation? -ANSWER-Outpatient
Which item is not an inpatient healthcare setting? -ANSWER-
Emergency department
High-quality clinical documentation is the basis for what standard? -
ANSWER-Gold standard
,What allows the diagnostic, treatment, and response of information of
the patient to be aggregated into a uniform data set? -ANSWER-
Coding
What part of the health record, usually located at the end the
document, provides a complete picture of the patient's diagnosis? -
ANSWER-Impression and plan
What description is an aspect of the coding professionals' job? -
ANSWER-Asking the physician about any gaps in documentation that
may represent an insufficiently documented diagnosis
What has been called the equalizer for prospective inpatient
reimbursement? -ANSWER-Severity-based DRG
What is the ultimate goal of the installation of the POA indicator? -
ANSWER-To consider severity, resource utilization, and quality
indicators in reimbursement
Within how many hours of discharge does the attending physician
normally provide the discharge summary to the coding department? -
ANSWER-24-48
Which form of documentation is the essence of the health record on
which the coder relies? -ANSWER-Progress notes
A query is necessary when a conflict in documentation exists between
an attending physician and which practitioner? -ANSWER-
Anesthesiologist
What does the fifth digit "1" represent with regard to the myocardial
infarction code? -ANSWER-Current admission
,What is suggested as a requirement for reflection of current medical
practices and supports worldwide epidemiology? -ANSWER-New
coding system
A 3M study suggested that the reimbursement impact on the
implementation of ICD-10-CM/PCS would be what? -ANSWER-
Minimal
What is the estimated negative impact of the top 25 MS-DRGs
mentioned in the text? -ANSWER-1.4 percent
What is the first step required to determine the facility specific impact
of ICD-10 implementation? -ANSWER-Begin dual coding
What is the principal tool used by CDI programs to enhance
efficiency? -ANSWER-Analytics
What should the facilities interested in investing in a CDI program
perform on data and documentation? -ANSWER-Objective analysis
When analyzing coding data, what system has one of the highest
levels of aggregation? -ANSWER-DRG
Which reimbursement method allows for multiple assignments for
each encounter and allows for the analysis of clinical documentation
to remain on the coding level? -ANSWER-APC
During the review of clinical documentation, on what is it imperative to
focus the review? -ANSWER-Current provider documentation
, Review of inconsistencies or patterns that do not meet DRG target
norms, allows this data to be used for what purpose? -ANSWER-
Clinical documentation Assessment
What are the two types of data the review team should consider in the
CDI analysis process? -ANSWER-Data produced by the organization;
data produced by others about the organization
Most organizations review data on a regular basis by ______, as part
of _______ analysis? -ANSWER-Diagnostic-Related Group; Case mix
Changes in these two rates may suggest problems with clinical
documentation? -ANSWER-Major complication or comorbidity and
complication or comorbidity
Which type of review takes place while the patient is still in the
hospital and when the patient leaves the hospitals? -ANSWER-
Concurrent; Retrospective
The ____________ is one of the key indicators used to monitor a
successful CDI program. -ANSWER-Capture rate
What is one important reason for having a CDI vision statement? -
ANSWER-It provides a purpose for the program
Prior to creating a vision statement for clinical documentation and CDI,
what is the first necessary step? -ANSWER-Invite discussion by
essential leaders in areas that might impact CDI process
Which committee should be comprised of executive management, a
physician advisor, a leader for clinical documentation and CDI, and
the manager of a CDI program? -ANSWER-Oversight
Study Guide Questions and Correct
Answers Rated A+
Which two medical professionals serve as mid-level practitioners by
supporting physicians in the delivery of care? -ANSWER-Nurse
practitioners and physician assistants
In 1982, which aspect of medical billing/reimbursement increased the
demand for accuracy and timeliness with regard to medical coding? -
ANSWER-Reimbursement was driven by codes assigned to patient
care
Which hands-on provider's documentation should the coder not use
for final coding? -ANSWER-Diagnostic radiologist
Which practitioners, along with coding professionals, are proficient at
picking up deficiencies in clinical documentation yet must focus on
giving care? -ANSWER-Nurses
Which healthcare setting requires high levels of proactivity from
management and clinical teams to ensure accurate and timely clinical
documentation? -ANSWER-Outpatient
Which item is not an inpatient healthcare setting? -ANSWER-
Emergency department
High-quality clinical documentation is the basis for what standard? -
ANSWER-Gold standard
,What allows the diagnostic, treatment, and response of information of
the patient to be aggregated into a uniform data set? -ANSWER-
Coding
What part of the health record, usually located at the end the
document, provides a complete picture of the patient's diagnosis? -
ANSWER-Impression and plan
What description is an aspect of the coding professionals' job? -
ANSWER-Asking the physician about any gaps in documentation that
may represent an insufficiently documented diagnosis
What has been called the equalizer for prospective inpatient
reimbursement? -ANSWER-Severity-based DRG
What is the ultimate goal of the installation of the POA indicator? -
ANSWER-To consider severity, resource utilization, and quality
indicators in reimbursement
Within how many hours of discharge does the attending physician
normally provide the discharge summary to the coding department? -
ANSWER-24-48
Which form of documentation is the essence of the health record on
which the coder relies? -ANSWER-Progress notes
A query is necessary when a conflict in documentation exists between
an attending physician and which practitioner? -ANSWER-
Anesthesiologist
What does the fifth digit "1" represent with regard to the myocardial
infarction code? -ANSWER-Current admission
,What is suggested as a requirement for reflection of current medical
practices and supports worldwide epidemiology? -ANSWER-New
coding system
A 3M study suggested that the reimbursement impact on the
implementation of ICD-10-CM/PCS would be what? -ANSWER-
Minimal
What is the estimated negative impact of the top 25 MS-DRGs
mentioned in the text? -ANSWER-1.4 percent
What is the first step required to determine the facility specific impact
of ICD-10 implementation? -ANSWER-Begin dual coding
What is the principal tool used by CDI programs to enhance
efficiency? -ANSWER-Analytics
What should the facilities interested in investing in a CDI program
perform on data and documentation? -ANSWER-Objective analysis
When analyzing coding data, what system has one of the highest
levels of aggregation? -ANSWER-DRG
Which reimbursement method allows for multiple assignments for
each encounter and allows for the analysis of clinical documentation
to remain on the coding level? -ANSWER-APC
During the review of clinical documentation, on what is it imperative to
focus the review? -ANSWER-Current provider documentation
, Review of inconsistencies or patterns that do not meet DRG target
norms, allows this data to be used for what purpose? -ANSWER-
Clinical documentation Assessment
What are the two types of data the review team should consider in the
CDI analysis process? -ANSWER-Data produced by the organization;
data produced by others about the organization
Most organizations review data on a regular basis by ______, as part
of _______ analysis? -ANSWER-Diagnostic-Related Group; Case mix
Changes in these two rates may suggest problems with clinical
documentation? -ANSWER-Major complication or comorbidity and
complication or comorbidity
Which type of review takes place while the patient is still in the
hospital and when the patient leaves the hospitals? -ANSWER-
Concurrent; Retrospective
The ____________ is one of the key indicators used to monitor a
successful CDI program. -ANSWER-Capture rate
What is one important reason for having a CDI vision statement? -
ANSWER-It provides a purpose for the program
Prior to creating a vision statement for clinical documentation and CDI,
what is the first necessary step? -ANSWER-Invite discussion by
essential leaders in areas that might impact CDI process
Which committee should be comprised of executive management, a
physician advisor, a leader for clinical documentation and CDI, and
the manager of a CDI program? -ANSWER-Oversight
