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CDI Top Exam Question and Answer Key. 100% Accurate. Graded A+
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CDI Top Exam Question and Answer Key. 100% Accurate. Graded A+ What is a reason a physician documentation can be difficult to review? - -Illegible handwriting The best scientific data available for clinical documentation is also known as - -Evidence-based medicine The two-part theory for...

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  • February 16, 2023
  • 17
  • 2022/2023
  • Exam (elaborations)
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CDI Top Exam Question and Answer
Key. 100% Accurate. Graded A+

What is a reason a physician documentation can be difficult to review? - ✔✔-Illegible handwriting



The best scientific data available for clinical documentation is also known as - ✔✔-Evidence-based
medicine



The two-part theory for high-quality clinical documentation is a cause-and-effect theory that is derived
from which two sources? - ✔✔-Legal/Regulatory Sources and Peer-Reviewed Research



When discussing completeness in a health record, the physician has fully addressed all concerns, as well
as what other authentication? - ✔✔-Signature and date



Peer-reviewed academic literature states that this factor shows a relationship to quality of care as well
as support for concurrent CDI programs: - ✔✔-Documentation



What evidence supports the lack of high-quality clinical documentation in the medical field? - ✔✔-CDI is
not taught in medical school



Which item is not recommended by the HHS and the OIG for minimum compliance with clinical
documentation regulations? - ✔✔-Physicians should include vaccination records



What does "reliable" in high-quality clinical documentation mean? - ✔✔-Physician documentation
supports medical treatment



Which item is an important aspect of consistent high-quality clinical documentation? - ✔✔-Creates a
clear picture for subsequent reviewers of documentation

,Which aspect of the discharge summary is the biggest challenge to house staff, mid-level practitioners,
and attending physicians as they compose the patient's discharge summary? - ✔✔-Timeliness



Which aspect of the patient's health record can a member of the house staff or midlevel practitioner
create, yet ultimately needs the attending physician to confirm accuracy? - ✔✔-Problem list



Interns, residents, and fellows are physicians with lesser accountability due to their inability to act as an
attending physician and are also known as ______. - ✔✔-House staff



Which two medical professionals serve as mid-level practitioners by supporting physicians in the
delivery of care? - ✔✔-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? - ✔✔-Reimbursement was driven by codes assigned to patient
care



Which hands-on provider's documentation should the coder not use for final coding? - ✔✔-Diagnostic
radiologist



Which practitioners, along with coding professionals, are proficient at picking up deficiencies in clinical
documentation yet must focus on giving care? - ✔✔-Nurses



Which healthcare setting requires high levels of proactivity from management and clinical teams to
ensure accurate and timely clinical documentation? - ✔✔-Outpatient



Which item is not an inpatient healthcare setting? - ✔✔-Emergency department



High-quality clinical documentation is the basis for what standard? - ✔✔-Gold standard



What allows the diagnostic, treatment, and response of information of the patient to be aggregated into
a uniform data set? - ✔✔-Coding

, What part of the health record, usually located at the end the document, provides a complete picture of
the patient's diagnosis? - ✔✔-Impression and plan



What description is an aspect of the coding professionals' job? - ✔✔-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? - ✔✔-Severity-based DRG



What is the ultimate goal of the installation of the POA indicator? - ✔✔-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? - ✔✔-24-48



Which form of documentation is the essence of the health record on which the coder relies? - ✔✔-
Progress notes



A query is necessary when a conflict in documentation exists between an attending physician and which
practitioner? - ✔✔-Anesthesiologist



What does the fifth digit "1" represent with regard to the myocardial infarction code? - ✔✔-Current
admission



What is suggested as a requirement for reflection of current medical practices and supports worldwide
epidemiology? - ✔✔-New coding system



A 3M study suggested that the reimbursement impact on the implementation of ICD-10-CM/PCS would
be what? - ✔✔-Minimal



What is the estimated negative impact of the top 25 MS-DRGs mentioned in the text? - ✔✔-1.4 percent

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