Free CDIP Exam Braindumps

A query should be generated when documentation contains a

1. A. postoperative hospital-acquired condition
2. B. principal diagnosis without an MCC
3. C. diagnosis without clinical validation
4. D. problem list with symptoms related to the chief complaint

Correct Answer: C
A query should be generated when documentation contains a diagnosis without clinical validation, meaning that there is no evidence in the health record to support the diagnosis or that the diagnosis is inconsistent with other clinical indicators. A diagnosis without clinical validation may affect the accuracy and completeness of coding, quality measures, reimbursement, and patient care.
References: AHIMA/ACDIS. ??Guidelines for Achieving a Compliant Query Practice (2019 Update).?? Journal of AHIMA 90, no. 2 (February 2019): 20-29.

Yes/No queries may be used

1. A. when only the clinical indicators of a condition are present
2. B. to resolve conflicting documentation from multiple practitioners
3. C. when the diagnosis is not clearly documented in the health record
4. D. in any query format

Correct Answer: B

Which of the following is an example of a hospital-acquired condition when not present on admission?

1. A. Iatrogenic pneumothorax with lung biopsy
2. B. Iatrogenic pneumothorax with venous catheterization
3. C. Pressure ulcer stage II
4. D. Pressure ulcer stage III

Correct Answer: D
A hospital-acquired condition (HAC) is an undesirable situation or condition that affects a patient and that arose during a stay in a hospital or medical facility. CMS has identified 14 categories of HACs for which it will not pay the higher DRG rate if the condition was not present on admission (POA). One of these categories is stage III and IV pressure ulcers. A pressure ulcer is damage to the skin and underlying tissue caused by prolonged pressure on the skin. Stage III pressure ulcers involve full-thickness skin loss with damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents as a deep crater with or without undermining of adjacent tissue.
* A. Iatrogenic pneumothorax with lung biopsy is not a HAC, because it is not included in the CMS HAC list. Iatrogenic pneumothorax is a HAC only when it occurs with venous catheterization.
* B. Iatrogenic pneumothorax with venous catheterization is a HAC, but it may be present on admission if the venous catheterization was performed before the admission to the hospital.
* C. Pressure ulcer stage II is not a HAC, because only stage III and IV pressure ulcers are included in the CMS HAC list. Stage II pressure ulcers involve partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
References:
✑ CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530
✑ Hospital Acquired Conditions | CMS
✑ ICD-10 HAC List | CMS
✑ Bedsores (pressure ulcers) - Symptoms and causes - Mayo Clinic

A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an
associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the
query as answered and agreed?

1. A. That the blood loss was not clinically significant
2. B. The associated diagnosis and the clinical rationale in the progress notes
3. C. A cause-and-effect relationship between anemia and the underlying cause
4. D. The associated diagnosis directly on the query form

Correct Answer: B
The physician needs to document the associated diagnosis and the clinical rationale in the progress notes for the CDIP to record the query as answered and agreed because this is the best way to ensure that the health record reflects the patient??s condition and treatment accurately and completely. The associated diagnosis is the condition that caused or contributed to the blood loss and the need for transfusion, such as acute blood loss anemia, hemorrhage, or trauma. The clinical rationale is the explanation of how the diagnosis is supported by the clinical indicators, such as laboratory values, vital signs, symptoms, or procedures. Documenting the associated diagnosis and the clinical rationale in the progress notes also helps to avoid any confusion or inconsistency with other parts of the health record, such as the discharge summary or the coding. (CDIP Exam Preparation Guide)
References:
✑ CDIP Exam Content Outline1
✑ CDIP Exam Preparation Guide2
✑ Guidelines for Achieving a Compliant Query Practice (2019 Update)3

Which of the following should an organization consider when developing a query retention policy and procedure?

1. A. If the query is considered part of the health record
2. B. How the query will be formatted
3. C. Who should be queried
4. D. What the escalation process will be

Correct Answer: A
One of the factors that an organization should consider when developing a query retention policy and procedure is if the query is considered part of the health record or not. According to the AHIMA/ACDIS query practice brief1, a query is considered part of the health record if
it meets any of the following criteria:
✑ It is used to clarify documentation that affects code assignment or other data elements
✑ It is used to support clinical validation of a diagnosis or procedure
✑ It is used to support medical necessity or quality indicators
✑ It is used to communicate clinical information between providers If a query is part of the health record, it should be retained according to the organization??s health record retention policy and procedure, which should comply with federal, state, and local laws and regulations. The query retention policy and procedure should also address issues such as:
✑ The format and location of the query (e.g., paper, electronic, hybrid)
✑ The security and confidentiality of the query
✑ The accessibility and availability of the query
✑ The ownership and custodianship of the query
✑ The legal implications and evidentiary value of the query
References:
✑ CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam- content-outline.pdf)
✑ Guidelines for Achieving a Compliant Query Practice—2022 Update1