CDI Top Exam Question and Answer Key. 100% Accurate. Graded A+

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 What is the first step required to determine the facility specific impact of ICD-10 implementation? - -Begin dual coding What is the principal tool used by CDI programs to enhance efficiency? - -Analytics What should the facilities interested in investing in a CDI program perform on data and documentation? - -Objective analysis When analyzing coding data, what system has one of the highest levels of aggregation? - -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? - -APC During the review of clinical documentation, on what is it imperative to focus the review? - -Current provider documentation Review of inconsistencies or patterns that do not meet DRG target norms, allows this data to be used for what purpose? - -Clinical documentation Assessment What are the two types of data the review team should consider in the CDI analysis process? - -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? - -Diagnostic-Related Group; Case mix Changes in these two rates may suggest problems with clinical documentation? - -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? - -Concurrent; Retrospective The ____________ is one of the key indicators used to monitor a successful CDI program. - -Capture rate What is one important reason for having a CDI vision statement? - -It provides a purpose for the program Prior to creating a vision statement for clinical documentation and CDI, what is the first necessary step? - -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? - -Oversight What committee is comprised of individuals responsible for day-to-day management and support for the CDI program? - -Operational What is the most essential role the oversight committee plays? - -Obtain and maintain support from the medical staff Which hospital leader should provide the initial announcement for the CDI program the organization installs? - -Chief executive officer When refreshing an existing CDI program, what is one of the recommendations when quality or mortality scores decline? - -Case audit to determine if it is a coding or clinical documentation issue What is one of the key concepts in communication regarding CDI the organization should consider? - -What media the organization will use to communicate it What is the key to success and sustainability of the CDI program? - -Physician support The operational committee is responsible for which process on an ongoing basis? - -Queries for high-quality clinical documentation Which executive must be involved in designing communication of the clinical documentation program from the start? - -Physician executive What must happen in order to obtain ultimate success with regard to clinical documentation? - -Adopt a program structure that fits the organization The advent of the EHR has increased the amount of documentation based largely due to: - -Ease of entry What is the minimum recommended length of training in clinical documentation for the CDI physician leader? - -40 hours When the CDI program encounters a problematic physician, who should control and resolve the situation? - -Physician leader for CDI Who must be a creative and out-of-the box thinker in order for the CDI program to be a success? - -Director of CDI department The CDI specialist is required to handle which day-to-day activities: - -Training staff, physicians, and health record review Who should be an effective physician communicator, and excellent at reading clinical documentation and data to uncover low-quality clinical documentation? - -Clinical documentation improvement practitioner A goal of every CDI program is to obtain high-quality clinical documentation _________. - -Prior to the patient being discharged from the hospital An effective CDI program should be able to capture 70 to 75 percent of the query responses _______. - -Concurrently What theory does the scientifically validated CAMP method for clinical documentation training draw upon? - -Adult learning theory of self-efficacy What is the keystone to every CDI program? - -Physician training What is vital to moving forward with a comprehensive physician-training program? - -Executive team and physician leader support Research based on the scientific method is used to demonstrate value to whom? - -Physicians Which member of the CDI training team is essential for optimal training outcomes? - -Peer physician Which CDI trainer should be well versed in clinical documentation principles, quality indicators, and coding and reimbursement methodologies? - -Nonphysician trainer Which type of physician is often top priority for CDI training and account for, on average, 60 percent of the hospital admissions? - -Hospitalist In the CAMP acronym, what does the M stand for? - -Mastering In the CAMP acronym, asking means: - -Asking for feedback from physician students at the right time A typical CAMP training program consists of: - -Four hours of training for physicians to learn core concepts The CDI staff training is recommended to be a three-part program. Which is one of the three parts? - -Program data collection and analysis What should be done after the entire training program is complete for CDI staff? - -Testing and self-evaluation Clinical documentation determines actual and perceived quality of care which makes it important to train CDI staff on what basics of Medicare? - -Quality indicators The health record review process and what other aspect allow for the highest level of quality in clinical documentation? - -Physician queries What should the CDI program staff do after the majority of classroom basics have been discussed? - -Case review on the nursing units The CDI specialists are partnered with the CDI trainees to discuss which aspect of the record review process? - -Sources of query opportunities Which tool is used by the CDI program staff to generate reports using entered data elements? - -CDI Monitor What can the CDI program staff generate by training the documenting clinicians on the CDI basics? - -Clinically valid queries Who should be given high priority CDI training due to their partnership with physicians? - -Nurses practitioners It is vital to provide CDI training to anyone who performs _______. - -Documentation in clinical records There is currently no benchmark for this metric; each organization should determine it: - -Physician response rate Which is a primary reason for the demand for high-quality clinical documentation? - -Code assignment Clinical documentation policies and procedures should: - -Be created by and specifically for each organization Though the goal for concurrent documentation review should be 100 percent, which type of inpatient stay makes it hard for any meaningful review? - -One-day stays Establishing the __________ rate is determined through the assessment process and could take several months. - -Target review If the agreement rate on retrospective queries for a physician is 100 percent, this could be a sign of: - -Leading queries With continued querying and follow-up training, what is the expected result? - -Query rate reduction What has been proven to produce higher levels of patient quality of care? - -Concurrent clinical documentation The CDI staff should perform concurrent record review on the ______ day of admission. - -Second Why should CDI staff be teamed up with a coding professional? - -To achieve CDI organizational goals What should be organization-specific with regard to key metrics? - -Metric targets It is important to report and analyze CDI key metrics in what form? - -Aggregate What should individual rates that are different from the target rates be? - -Investigated for significance The purpose of ______________ is to identify any gaps in knowledge or skills for appropriate corrective action. - -Compiling and analyzing key metrics Hospitals often track the physician response rate. What could a level lower than benchmark reflect? - -Lack of physician-hospital alignment In general, hospitals have higher quality scores when _____________. - -The majority of patients are grouped in the higher severity levels Which is the average DRG relative weight for inpatient cases and an indicator of average reimbursement per patient? - -Case mix index What term refers to the change in average reimbursement per patient that occurs when different types of patients are being admitted as compared to another period of time? - -Real patient mix change What occurs when a change in CMI occurs due to changes in documentation practice? - -CDI case mix change Higher quality clinical documentation is a primary contributor to a higher level of __________. - -Severity level accuracy Which is an important component of follow-up education? - -Testing A convenience sampling methodology implies: - -Selecting cases that are convenient to retrieve What type of testing is best taken post-training? - -Multiple choice What is one key component of a compliant CDI program? - -Documented, mandatory physician education Detailed query documentation can be used to: - -Protect the hospital against claims from physicians about leading queries A comprehensive retrospective review should be conducted at least once a year of what aspect of the CDI program? - -All query opportunities Qualified individuals who are not involved in the day-to-day operations of the CDI program should conduct a____________? - -Retrospective record audit Which plan should be devised to respond to issues arising from the CDI compliance and operational audit process? - -Corrective action plan What is the goal of the CDI compliance review? - -Compliant query generation and physician responses When conducting an audit review of records for CDI, what would the minimum number of records to pull be? - -30 Generally, initial CDI implementation programs should: - -Plan expansion in small steps Why is it important to obtain support of the medical staff when creating a physician report card? - -It could harm hospital-physician relationships