CDIP EXAM LATEST 2024-2025(CERTIFIED DOCUMENTATION
INTEGRITY PRACTITIONER) WITH ACTUAL QUESTIONS AND
CORRECT VERIFIED ANSWERS ALREADY GRADED A+ 100%
GUARANTEED PASS!
CDI program data includes: - ANSWER-1. All cases that were reviewed
2. Number of cases with queries
3. Nature of the query
4. Physician response to the query
Queries should only be asked: - ANSWER-1. If there is clinical evidence that the
documentation is imcomplete or does not meet one of the seven criteria for
high-quality clinical documentation.
2. By an individual with solid clinical knowledge.
3. In an open-ended manner (no yes or no questions)
4. In a nonleading manner.
5. To the individual whose documentaion is in question or who is responible for
interpreting test results or other data in the patient's record.
Query process and procedure should address: - ANSWER-1. When queries will
be asked.
2. Who will ask queries and to whom queries will be asked.
3. The hospital's responsibility in supporting the quering process.
4. The physician's responsibility in responding to queries.
,5. Acceptable ways to responding to queries.
Examples of when a query is required may include: - ANSWER-1.
Documentation of reportable conditions or procedures is conflicting,
ambigious, or is otherwise incomplete.
2. Abnormal diagnostic test results indicate the possible addition of a
secondary diagnosis or higher specificity of an already documented condition.
3. The patient is receiving treatment for a condition that has not been
documented.
4. Abnormal operative or procedureal findings are not documented.
5. It is unclear as to whether a condition was ruled out.
6. The pricipal diagnosis is not clearly identified.
Septicemia - ANSWER-A systemic disease with the presence and persistence of
pathogenic micro-organisms or toxins in the blood. No longer considered
synonymous with sepsis.
Sepsis - ANSWER-Sepsis is SIRS due to an infection . Infection can originate
anywhere in the body and be triggered by a bacterial, viral, parasitic, or fungal
infection.
Severe Sepsis - ANSWER-SIRS due to infection with organ dysfunction.
Sepsis associated with acute dysfunction in one or more organs.
Organ dysfunction bay be cardiovascular, renal, respiratory, hepatic,
hematological, central nervous system, or metabolic acidosis.
SIRS - ANSWER-SIRS is the systemic response to infection or trauma.
The systemic response is manifested by a variety of clinical signs and symptoms
such as:
, Fever (>100.4 degrees F), Hypothermia (<96.8 degrees F), WBC >= to 12000
cellsmm3 (leukocytosis), WBC <= to 4000 cells/mm3 or 10% immature cells,
heart reat >90 bpm, respirations >20 breaths/minute or PcCO2 <32 mg of
mercury, hypotension, altered mental status.
Septic Shock - ANSWER-Sepsis with hypotension or a failure of the
cardiovascular system.
Endotoxic shock and gram negative shock are synomymous with septic shock,
septic shock = severe sepsis
Bacteremia - ANSWER-Bacteria in the blood without an associated
inflammatory response.
Denotes laboratory findings of viable bateria in the blood with no systemic
manifestations.
Progresses to septicemia only when there is a more severe infections process
or an impaired immune system.
Urosepsis - ANSWER-Infection confined to the urinary system.
Refers to pyuria or bacteria in the urine (not in the blood).
Query the physician to determine if the bacteria in the urine has progressed to
septicemia or sepsis.
EBM - ANSWER-Evidence Based Medicine-practicing medicine using only the
best scientific data available.
, Four kinds of standards in EBM - ANSWER-Design Performance
Terminology Procedural
Theory of high-quality of clinical documentation - ANSWER-If the 7 criteria of
high-quality clinical documentation are applied ot clinical documentation, then
clinical documentation quality will be high and the accuracy of care, quality
indicators, reimbursement, healthcare planning, and research will be improved.
What year was TEFRA (Tax Equity and Fiscal Responsibility Act) implemented? -
ANSWER-1982
DRGs - ANSWER-Developed by Yale in the 70's to describe all types of patient
care in an acute care hospital. Implemented for Medicare IPP in 1983.
AP-DRGs - ANSWER-Implemented in 1987 by 3m. For NY non-Medicare
discharges reimbursement program.
APR-DRGs - ANSWER-Developed by 3m in 1990; addressed severity of illness
and risk of mortality over all patient populations.
When did CMS adopt MS-DRGs to better recognize severity of illness (SOI) in
Medicare IPPS? - ANSWER-FY2007
CY2008
Comorbidity - ANSWER-A pre-existing condition which because of it's presence
with the principal diagnosis will increase the LOS by at least 1 day in
approximately 75% of cases.
Complication - ANSWER-A condition arising in a hospital that prolongs the LOS
by at lease one day in approximately 75% of cases.
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