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 documen ...

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 highquality 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 t