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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: 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 |
| Topic 2: Clinical Coding Practice | 22–26% | - Payer requirements and reimbursement models - Coding software and reference resources - ICD-10-CM/PCS coding conventions and guidelines - Principal and secondary diagnosis identification - DRG, CPT, and HCPCS code assignment |
| Topic 3: Compliance | 4–8% | - AHIMA standards and regulatory requirements - Compliance monitoring and reporting - Legal and ethical documentation practices - Fraud and abuse prevention |
| Topic 4: Research & Education | 11–15% | - Regulatory and guideline updates - Provider and staff education - Best practice research and implementation - Documentation improvement training materials |
| Topic 5: CDI Metrics & Statistics | 14–18% | - Query response and volume tracking - Benchmarking and reporting - DRG comparison and denial analysis - Quality audits and compliance monitoring |
| Topic 6: Leadership | 17–22% | - Policy and procedure creation - Interdisciplinary collaboration - CDI program development and promotion - Provider engagement and communication |
1. Reviewing and analyzing physician query content on a regular basis
A) helps to calculate query response rate
B) aids in discussion between physician and reviewer
C) facilitates physician data collection
D) assists in identifying gaps in skills and knowledge
2. A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?
A) Read the nursing admission notes
B) Query the attending provider
C) Review the history and physical
D) Look for wound care documentation
3. Which of the following is nonessential to facilitate code capture when educating clinical staff on documentation practices associated with diabetes mellitus?
A) Type
B) Manifestation
C) Age
D) Cause
4. Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?
A) Reporting and the use of technology
B) Diagnostic related groups and revenue cycle
C) Value and mission statements
D) Benchmarks and case mix index
5. Tracking denials within the clinical documentation integrity program is important to
A) identify documentation improvement opportunities and educate as necessary
B) file a timely appeal if the medical center disagrees with the RAC findings
C) confirm reimbursement was appropriate
D) determine coding inaccuracies and educate as necessary
Solutions:
| Question # 1 Answer: D | Question # 2 Answer: C | Question # 3 Answer: C | Question # 4 Answer: C | Question # 5 Answer: A |
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