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The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to

1. A. provide community education to healthcare consumers
2. B. create synergy between clinical education and CDI principles
3. C. show a direct relationship between clinical documentation and quality patient care
4. D. promote CDI functions so that physicians view the CDI staff as value-added service

Correct Answer: C
The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to show a direct relationship between clinical documentation and quality patient care. According to the web search results, CDI programs aim to improve the quality and efficiency of clinical documentation by ensuring that it is accurate, complete, and consistent. This in turn leads to better health care data, which is vital for capturing the appropriate indicators used for health care facility and provider profiling, reimbursement, risk adjustment, and quality scores12. CDI programs also focus on patient safety, by identifying and resolving any documentation omissions, discrepancies, or adverse events that may affect the patient??s outcome or care3. Therefore, CDI programs demonstrate how clinical documentation can impact the quality of patient care and the performance of health care organizations.

A 56-year-old male patient complains of feeling fatigued, has nausea & vomiting, swelling in both legs. Patient has history of chronic kidney disease (CKD) stage III, coronary artery disease (CAD) & hypertension (HTN). He is on Lisinopril. Vital signs: BP 160/80, P 84, R 20, T 100.OF. Labs: WBC 11.5 with 76% segs, GFR 45. CXR showed slight left lower lobe haziness. Patient was admitted for acute kidney injury (AKI) with acute tubular necrosis (ATN). He was scheduled for hemodialysis thenext day. Two days after admission patient started coughing, fever of 101.8F, CXR showed left lower lobe infiltrate, possible pneumonia. Attending physician documented that patient has pneumonia and ordered Rocephin IV. How should the clinical documentation integrity practitioner (CDIP) interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC)?

1. A. D
2. B. Adair, in your clinical opinion, do you think that the patient's acute kidney injury with ATN exacerbated the patient's pneumonia?
3. C. No need to query the physician because even if the pneumonia is considered a HAC and cannot be used as an MCC, ATN is also an MCC.
4. D. No need to interact with the physician because it is obvious the pneumonia developed after admission, therefore, not present on admission.
5. E. D
6. F. Adair, please indicate if the patient's pneumonia was present on admission (POA) based on the initial chest x-ray?

Correct Answer: D
The clinical documentation integrity practitioner (CDIP) should interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC) by asking the physician to indicate if the pneumonia was present on admission (POA) based on the initial chest x-ray. This is because the POA status of a condition affects its coding, reporting, and reimbursement, and it is the responsibility of the physician to document the POA status of all diagnoses. The CDIP should not assume that the pneumonia developed after admission based on the timing of symptoms or treatment, as this may not reflect the true clinical picture. The CDIP should also not ask the physician about the causal relationship between the acute kidney injury and the pneumonia, as this is not relevant to the POA status. The CDIP should also not avoid querying the physician based on the presence of another MCC, as this may compromise the accuracy and completeness of documentation. (CDIP Exam Preparation Guide)
References:
✑ CDIP Exam Content Outline
✑ CDIP Exam Preparation Guide
✑ Present on Admission Reporting Guidelines

A hospital administrator has hired a clinical documentation integrity (CDI) firm to improve its revenue objectives. The physicians object to this action. How should the firm collaborate with physicians to overcome their objections?

1. A. Create a vision statement that outlines the project objectives
2. B. Communicate the benefits of the CDI firm about the project
3. C. Hire a consultant to communicate the benefits to the physicians
4. D. Identify an influential physician advisor/champion to promote support

Correct Answer: D
A physician advisor/champion is a physician leader who supports and advocates for the CDI program and its objectives. A physician advisor/champion can help overcome the objections of other physicians by providing education, feedback, guidance, and mentorship on documentation best practices and their impact on revenue, quality, and patient care. A physician advisor/champion can also act as a liaison between the CDI firm and the medical staff, resolve conflicts or discrepancies in documentation, and foster a culture of collaboration and improvement. Physicians are more likely to trust and engage with their peers who understand their clinical perspective and challenges, rather than an external CDI firm that may be perceived as intrusive or disruptive.
* A. Create a vision statement that outlines the project objectives. This is not sufficient to collaborate with physicians and overcome their objections. A vision statement is a general statement that describes the desired outcome of the project, but it does not address the specific concerns or questions that physicians may have about the CDI firm??s role, methods, or benefits.
* B. Communicate the benefits of the CDI firm about the project. This is not enough to collaborate with physicians and overcome their objections. Communicating the benefits of the CDI firm may be informative, but it may not be persuasive or credible if it comes from the CDI firm itself, without any endorsement or support from a physician leader within the organization.
* C. Hire a consultant to communicate the benefits to the physicians. This is not a good way to collaborate with physicians and overcome their objections. Hiring a consultant may add another layer of complexity and cost to the project, and it may not improve the trust or relationship between the CDI firm and the physicians. A consultant may also lack the clinical expertise or authority to influence the physicians?? behavior or attitude. References:
✑ CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
✑ Q&A: Defining roles for physician advisor/champion | ACDIS
✑ Q&A: The Role of the Physician Advisor in CDI | ACDIS
✑ The Role of a Physician Advisor - UASI Solutions
✑ PA/NP in Physician Champion / Advisor Role — ACDIS Forums

The key component of the auditing and monitoring process to ensure provider query response is to

1. A. audit individual providers to indicate improvement in health record documentation
2. B. have a process in place for ongoing education and training of the staff involved in conducting provider queries
3. C. make sure that the language in the query is not leading or otherwise inappropriate
4. D. review queries retrospectively to ensure that they are completed according to documented Policies and procedures

Correct Answer: D

A modifier may be used in CPT and/or HCPCS codes to indicate

1. A. a service or procedure was increased or reduced
2. B. a service or procedure was performed in its entirety
3. C. a service or procedure resulted in expected outcomes
4. D. a service or procedure was performed by one provider

Correct Answer: A
According to the AHIMA CDIP Exam Preparation Guide, a modifier is a two-digit numeric or alphanumeric code that may be used in CPT and/or HCPCS codes to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code1. One of the reasons to use a modifier is to indicate that a service or procedure was increased or reduced in comparison to the usual service or procedure2. For example, modifier 22 can be used to report increased procedural services that require substantially greater time, effort, or complexity than the typical service3. The other options are not correct because they do not reflect the purpose of using modifiers. A service or procedure performed in its entirety does not need a modifier, as it is assumed to be the standard service or procedure. A service or procedure resulting in expected outcomes does not affect the coding or reimbursement of the service or procedure. A service or procedure performed by one provider may need a modifier depending on the type of provider, the place of service, and the payer rules, but it is not a general reason to use a modifier.
References:
✑ CDIP Exam Preparation Guide - AHIMA
✑ Modifiers: A Guide for Health Care Professionals - CMS
✑ CPT® Modifiers: 22 Increased Procedural Services | AAPC