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| Section | Weight | Objectives |
|---|---|---|
| Compliance | 4–8% | - Fraud and abuse prevention - AHIMA standards and regulatory requirements - Legal and ethical documentation practices - Compliance monitoring and reporting |
| Research & Education | 11–15% | - Documentation improvement training materials - Provider and staff education - Regulatory and guideline updates - Best practice research and implementation |
| CDI Metrics & Statistics | 14–18% | - Query response and volume tracking - Benchmarking and reporting - DRG comparison and denial analysis - Quality audits and compliance monitoring |
| Clinical Coding Practice | 22–26% | - DRG, CPT, and HCPCS code assignment - Coding software and reference resources - Payer requirements and reimbursement models - ICD-10-CM/PCS coding conventions and guidelines - Principal and secondary diagnosis identification |
| Leadership | 17–22% | - Policy and procedure creation - Provider engagement and communication - CDI program development and promotion - Interdisciplinary collaboration |
| Record Review & Document Clarification | 24–28% | - Compliance with query standards - Query tracking and follow-up - Identify documentation gaps and specificity issues - Ethical provider query development - POA, HAC, SOI, ROM clarification |
1. Which of the following falls under the False Claims Act?
A) Missing charges
B) Missing diagnosis codes
C) Missing modifiers
D) Unbundling services
2. Which of the following should an organization consider when developing a query retention policy and procedure?
A) If the query is considered part of the health record
B) How the query will be formatted
C) What the escalation process will be
D) Who should be queried
3. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?
A) Coders can rely on the laboratory results to confirm the patient's diagnosis
B) Errors are corrected by the clinician who authored the documentation
C) Any physician caring for the patient can correct inaccurate record notes
D) Amendments to record content must be co-signed by the attending physician
4. A clinical documentation integrity (CDI) program that is compliant with regulations from the facility's payors results in
A) higher overall program cost
B) need for more CDI staff
C) meeting external benchmarks
D) less risk from audits
5. A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate
A) initial
B) sequela
C) aftercare
D) subsequent
Solutions:
| Question # 1 Answer: D | Question # 2 Answer: A | Question # 3 Answer: B | Question # 4 Answer: D | Question # 5 Answer: C |
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