AHIMAは2024年最新のCDIPテスト解説（更新されたのは140問があります)
CDIP試験問題集を提供していますAHIMA問題
質問 # 36
A clinical documentation integrity practitioner (CDIP) is looking for clarity on whether a diagnosis has been
"ruled in" or "ruled out". Which type of query is the best option?
- A. None
- B. Multiple-choice
- C. Open-ended
- D. Yes/No
正解：C
解説：
Explanation
An open-ended query is a type of query that allows the provider to respond with free text, rather than choosing from a list of options or answering yes or no. An open-ended query is appropriate when the CDIP is looking for clarity on whether a diagnosis has been "ruled in" or "ruled out", because it allows the provider to document the final diagnosis or impression based on the clinical evidence and reasoning. An open-ended query also avoids leading or suggesting a specific diagnosis to the provider, which could compromise the integrity and validity of the documentation. (Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1) References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1
質問 # 37
Combination codes are used to classify two diagnoses, a diagnosis with a manifestation, or a diagnosis
- A. with a sequelae or late effect
- B. with an associated procedure
- C. that is an integral part of a disease process
- D. with an associated complication
正解：D
解説：
Explanation
Combination codes are used to classify two diagnoses, a diagnosis with a manifestation, or a diagnosis with an associated complication. A complication is a condition that arises during the hospital stay that prolongs the length of stay by at least one day in approximately 75 percent of cases1. Complications may affect payment and severity of illness and risk of mortality classifications. Examples of combination codes that include a diagnosis with an associated complication are:
I50.23 Acute on chronic systolic (congestive) heart failure
K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding O34.211 Maternal care for incompetent cervix with cerclage, first trimester A diagnosis that is an integral part of a disease process is not a valid option for combination codes, because it does not represent a separate or additional condition that needs to be coded. For example, chest pain is an integral part of acute myocardial infarction and does not require a separate code.
A diagnosis with an associated procedure is not a valid option for combination codes, because procedures are coded separately from diagnoses using ICD-10-PCS codes. For example, appendicitis with appendectomy is not a combination code, but rather two codes: one for the diagnosis (K35.80 Acute appendicitis without perforation or gangrene) and one for the procedure (0DTJ4ZZ Resection of appendix, percutaneous endoscopic approach).
A diagnosis with a sequelae or late effect is not a valid option for combination codes, because sequelae or late effects are coded separately from the original condition using the appropriate code from category B90-B94 Sequelae of infectious and parasitic diseases or category I69 Sequelae of cerebrovascular disease, followed by the code for the specific condition2. For example, hemiplegia following cerebral infarction is not a combination code, but rather two codes: one for the sequelae (I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side) and one for the original condition (I63.9 Cerebral infarction, unspecified).
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 ICD-10-CM Official Guidelines for Coding and Reporting FY 2022 Identifying ICD-10 Combination Codes - Outsource Strategies International
質問 # 38
Which of the following indicates a noncompliant multiple-choice query? One that does NOT
- A. allow the provider to add their own response
- B. include at least four options
- C. list options in alphabetical order
- D. include the option of "unable to determine"
正解：B
解説：
Explanation
A noncompliant multiple-choice query is one that does not include at least four options because it may limit the provider's choice and suggest a preferred answer. A compliant multiple-choice query should include at least four options that are clinically significant, reasonable, and plausible based on the clinical indicators and documentation in the health record. The options should also be listed in alphabetical order to avoid any bias or preference. A compliant multiple-choice query should also allow the provider to add their own response if none of the options are appropriate, and include the option of "unable to determine" if the provider cannot make a definitive diagnosis based on the available information. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Guidelines for Achieving a Compliant Query Practice (2019 Update)3
質問 # 39
The provider was queried because the patient met clinical criteria for acute hypoxic respiratory failure. The response to the query was different than what was expected by the clinical documentation integrity practitioner (CDIP). What should the CDIP do?
- A. Implement the department's escalation process
- B. Have a different CDIP query the provider
- C. Revise the query and send it back to the provider
- D. Record the query response as disagreed
正解：A
解説：
Explanation
If the provider's response to the query is different than what was expected by the CDIP, the CDIP should implement the department's escalation process to ensure the validity and accuracy of the documentation and the coded data. The escalation process is a standardized procedure that involves a manager, committee, or other supervisory position to review and assess the query and the response, and to determine the appropriate next steps. The escalation process may include contacting the provider for clarification, education, or feedback; consulting with a physician advisor/champion or a coding auditor; or reporting the issue to a higher authority or regulatory body. The escalation process should be documented and communicated clearly and respectfully to all parties involved.
A: Record the query response as disagreed. This is not a sufficient action to take if the provider's response to the query is different than what was expected by the CDIP. Recording the query response as disagreed may indicate a lack of agreement or consensus between the CDIP and the provider, but it does not address the underlying issue of documentation validity or accuracy. It may also create a negative impression or relationship between the CDIP and the provider.
B: Have a different CDI query the provider. This is not an appropriate action to take if the provider's response to the query is different than what was expected by the CDIP. Having a different CDI query the provider may create confusion, inconsistency, or redundancy in the query process. It may also undermine the credibility or authority of the original CDI who queried the provider.
C: Revise the query and send it back to the provider. This is not a recommended action to take if the provider's response to the query is different than what was expected by the CDIP. Revising the query and sending it back to the provider may imply that the CDI is dissatisfied or disagreeing with the provider's response, which may be perceived as disrespectful or confrontational. It may also suggest that the CDI is trying to influence or coerce the provider to change their response, which may compromise the integrity and compliance of the query process.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Guidelines for Achieving a Compliant Query Practice-2022 Update | ACDIS Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA The Provider Query Toolkit: A Guide to Compliant Practices
質問 # 40
Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include
- A. performing data analysis
- B. developing query forms
- C. educating physicians
- D. querying physicians
正解：C
解説：
Explanation
Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include educating physicians on the importance and impact of clinical documentation on coding, reimbursement, quality measures, compliance, and patient care. The physician advisor/champion can act as a liaison between the CDIPs and the medical staff, provide feedback and guidance on query development and resolution, and facilitate peer-to-peer education sessions on documentation best practices and standards6 References: 1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 6:
https://my.ahima.org/store/product?id=67077
質問 # 41
The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?
- A. Allow physician responses via e-mail
- B. Provide education to physicians on query process
- C. Require the CDIP to call physicians to follow up
- D. Update medical records with unsigned physician responses
正解：B
解説：
Explanation
According to the AHIMA/ACDIS Query Practice Brief, one of the best practices for a compliant query process is to provide ongoing education to physicians on the importance of documentation integrity, the query process, and the impact of documentation on quality measures, reimbursement, and compliance1. Education can help physicians understand the rationale and expectations for responding to queries, as well as the benefits of accurate and complete documentation for patient care and data quality. Education can also address any barriers or challenges that physicians may face in responding to queries, such as time constraints, technology issues, or workflow preferences1. References:
AHIMA/ACDIS Query Practice Brief - Updated 12/2022
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA
質問 # 42
A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for psuedomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would
- A. not increase relative weight
- B. not meet medical necessity
- C. meet medical necessity
- D. increase relative weight
正解：D
解説：
Explanation
The specificity of pseudomonas pneumonia would increase the relative weight of the diagnosis-related group (DRG) for the patient's admission, which would affect the reimbursement for the hospital. Relative weight is a factor that reflects the average cost and resource use of a DRG compared to the average cost and resource use of all DRGs. The higher the relative weight, the higher the payment for the hospital. Pseudomonas pneumonia is classified as a major complication or comorbidity (MCC) in ICD-10-CM, which means that it significantly increases the severity of illness and risk of mortality of the patient. MCCs increase the relative weight of a DRG by assigning it to a higher-paying subclass within the same base DRG. For example, according to the CMS FY 2022 Inpatient Prospective Payment System Final Rule1, the relative weight for DRG 193 (Simple pneumonia and pleurisy with MCC) is 1.4819, while the relative weight for DRG 195 (Simple pneumonia and pleurisy without MCC) is 0.7579. Therefore, if the patient is admitted due to pneumonia and has pseudomonas pneumonia as an MCC, the hospital would receive a higher payment than if the patient does not have an MCC.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) CMS FY 2022 Inpatient Prospective Payment System Final Rule1
質問 # 43
A clinical documentation integrity practitioner (CDIP) has been successful in getting physicians to respond to queries. However, when the CDIP poses a query to a specific doctor, there is no response at all. The CDIP has tried face-to-face conversations, calling, emails, texts, but still gets no response. What is the next step the CDIP should take?
- A. Report the doctor to the Vice President of Medical Affairs so the doctor understands the importance of clinical documentation
- B. Elevate the issue to the physician advisor/champion after the CDI supervisor has reviewed the case and deemed the query appropriate
- C. Warn the other CDIPs that the doctor is a non-responder and to forego querying
- D. Hold a meeting with the CDI director and the doctor to find out why the doctor is not responding to the queries
正解：B
解説：
Explanation
According to the Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1, a query escalation policy should describe how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, the department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for the organization1. In this case, since the CDIP has tried multiple methods of communication with the doctor but still gets no response, the CDIP should elevate the issue to the physician advisor/champion, who can facilitate communication and education with the doctor and ensure documentation integrity and compliance1. However, before escalating the issue, the CDIP should consult with the CDI supervisor to review the case and confirm that the query is appropriate, relevant, and compliant with the query guidelines1. This would ensure that the escalation is justified and not based on personal bias or preference.
The other options are not advisable because they either involve skipping the escalation policy, reporting the doctor without proper review or feedback, holding a meeting without involving the physician advisor/champion, or giving up on querying altogether.
References:
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA1
質問 # 44
A clinical documentation integrity practitioner (CDIP) is developing a plan to promote the CDI program throughout a major hospital. It is proving challenging to find support. What is a primary step for the CDIP?
- A. Determine primary interests of an individual or department
- B. Teach nursing staff about documentation integrity
- C. Determine primary interests and needs as requested
- D. Teach coding classes to the new physicians as needed
正解：A
解説：
Explanation
A primary step for the CDIP to promote the CDI program throughout a major hospital is to determine the primary interests of an individual or department that could benefit from or support the CDI program. This is because different stakeholders may have different motivations, expectations, and challenges related to CDI, and the CDIP should tailor the communication and education strategies accordingly. For example, physicians may be interested in how CDI can improve their quality metrics, reimbursement, and patient outcomes; coders may be interested in how CDI can reduce coding errors, denials, and queries; and executives may be interested in how CDI can enhance revenue integrity, compliance, and reputation. By identifying the primary interests of each individual or department, the CDIP can demonstrate the value and relevance of the CDI program, address any barriers or concerns, and foster collaboration and engagement 23.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: How to Promote Your Clinical Documentation Improvement Program 3: How to Market Your Clinical Documentation Improvement Program
質問 # 45
A noncompliant query includes querying the provider regarding
- A. morbid obesity due to BMI of 40.9 documented on the history and physical
- B. sepsis that was present on admission because sepsis was only documented in the discharge summary
- C. gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators
- D. acute blood loss anemia due to low hemoglobin treated with iron supplements
正解：C
解説：
Explanation
A noncompliant query includes querying the provider regarding gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators because it may lead to over-specification of a diagnosis that is not supported by the health record. A compliant query should be based on the clinical evidence and documentation in the record, and should not suggest or imply a diagnosis that is not clinically relevant or plausible. A query should also not be driven by reimbursement or coding factors, but by the need to improve the quality and accuracy of documentation. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
Guidelines for Achieving a Compliant Query Practice (2019 Update)3
質問 # 46
When are concurrent queries initiated?
- A. After the health record has been coded
- B. While the patient is hospitalized
- C. After discharge of the patient
- D. Before patient is admitted
正解：B
質問 # 47
An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are
- A. PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure - B. PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion - C. PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion - D. PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure
正解：B
解説：
Explanation
According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023, the principal diagnosis is defined as "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"2. In this case, the patient was admitted with shortness of breath, productive yellow sputum, and a temperature of 101.2, which are signs and symptoms of pneumonia. The CXR confirmed the diagnosis of LLL pneumonia, which is a serious condition that requires inpatient care. Therefore, LLL pneumonia is the principal diagnosis.
The secondary diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay"2. In this case, the patient had bilateral pleural effusion and kidney failure at the time of admission, which are coexisting conditions that affect the treatment received and/or the length of stay. The renal consult documented AKI with ATN, which is a more specific diagnosis than kidney failure and reflects the severity and etiology of the condition. Therefore, AKI with ATN and bilateral pleural effusion are secondary diagnoses.
References:
CDI Week 2020 Q&A: CDI and key performance indicators1
ICD-10-CM Official Guidelines for Coding and Reporting FY 20232
質問 # 48
Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?
- A. Chief Financial Officer
- B. Chief Medical Officer
- C. Compliance Officer
- D. CDI practitioner
正解：B
解説：
Explanation
The clinical documentation integrity (CDI) manager should consult the Chief Medical Officer when developing query policy and procedures because the Chief Medical Officer is responsible for overseeing the quality and safety of patient care, ensuring compliance with regulatory and accreditation standards, and providing leadership and guidance to the medical staff. The Chief Medical Officer can help to establish the goals, scope, and authority of the CDI program, as well as to support the query process and promote provider education and engagement. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
質問 # 49
A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?
- A. Query for a diagnosis associated with the dietician's finding of malnutrition
- B. Query for malignant pleural effusion
- C. Query if the malignant pleural effusion is the reason for admission
- D. Query for protein calorie malnutrition
正解：B
解説：
Explanation
According to the AHIMA CDIP Exam Preparation Guide, a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment1. A query should be clear, concise, and consistent, and should include relevant clinical indicators that support the query1. A query should also provide multiple choice answer options that are supported by clinical indicators and include a non-leading query statement2. In this case, the patient has a large right lung pleural effusion related to lung cancer stage II, which is documented multiple times. However, the documentation does not specify whether the pleural effusion is malignant or not. A malignant pleural effusion is a condition where cancer cells spread to the pleural space and cause fluid accumulation3. A malignant pleural effusion is a major complication or comorbidity (MCC) that affects the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality scores of the hospital4. Therefore, a post discharge query opportunity should be sent to the physician to clarify whether the pleural effusion is malignant or not, based on the clinical indicators such as chest x-ray, thoracentesis, and fluid analysis. The query should provide answer options such as malignant pleural effusion, non-malignant pleural effusion, unable to determine, or other. The other options are not correct because they either do not affect the SOI/ROM of the patient (A and C), or they do not address the specificity of the diagnosis (D). References:
CDIP Exam Preparation Guide - AHIMA
Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA Malignant Pleural Effusion: Symptoms, Causes, Diagnosis & Treatment Q&A: Coding for malignant pleural effusions | ACDIS
質問 # 50
Proposed changes to the inpatient prospective payment system (IPPS) take effect on
- A. July 1
- B. January 1
- C. October 1
- D. April 1
正解：C
解説：
Explanation
Proposed changes to the inpatient prospective payment system (IPPS) take effect on October 1 of each fiscal year (FY), which begins on October 1 and ends on September 30 of the next calendar year. The IPPS final rule is usually issued by the Centers for Medicare & Medicaid Services (CMS) around August 1 of each year, and it updates the Medicare payment policies and rates for acute care hospitals and long-term care hospitals for the upcoming FY. The effective date of the final rule is October 1, unless otherwise specified by CMS 2.
References: 1: Inpatient Prospective Payment System (IPPS) 2023 Final Rule Summary of ... 3 2: Acute Inpatient PPS | CMS 1
質問 # 51
When benchmarking with outside organizations, the clinical documentation integrity practitioner (CDIP) must determine if the organization is benchmarking with which of the following criteria?
- A. Hospital within its county
- B. Hospitals that are its peers
- C. Hospital within its state
- D. Hospital within its region
正解：B
解説：
Explanation
When benchmarking with outside organizations, the clinical documentation integrity practitioner (CDIP) must determine if the organization is benchmarking with hospitals that are its peers because peer hospitals have similar characteristics such as size, location, teaching status, case mix index, and payer mix. Benchmarking with peer hospitals allows for a more accurate and meaningful comparison of performance indicators and outcomes. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
質問 # 52
Which of the following can be evidence of physician-hospital alignment?
- A. A low physician agreement rate
- B. A high physician response rate
- C. A high physician agreement rate
- D. A high clinical documentation integrity practitioner (CDIP) query rate
正解：C
解説：
Explanation
A high physician agreement rate can be evidence of physician-hospital alignment because it indicates that the physicians are supportive of the clinical documentation integrity (CDI) program and its goals, and that they are willing to provide accurate and complete documentation in response to CDI queries. A high physician agreement rate also reflects a positive relationship and communication between the CDI team and the physicians, as well as a mutual understanding of the benefits of CDI for patient care, quality reporting, and reimbursement. (CDIP Exam Preparation Guide) References:
CDIP Exam Content Outline1
CDIP Exam Preparation Guide2
質問 # 53
What is the term used when a patient is entered in the Master Patient Index (MPI) multiple times, in different ways, resulting in multiple medical record numbers?
- A. Facsimile
- B. Clone
- C. Overlap
- D. Replica
正解：C
解説：
Explanation
The term used when a patient is entered in the MPI multiple times, in different ways, resulting in multiple medical record numbers is overlap. An overlap occurs when a person has more than one medical record number within an integrated delivery network or enterprise, and may cause problems such as incomplete or inaccurate patient information, duplicate testing or treatment, billing errors, or patient safety issues. An overlap may be caused by data entry errors, system conversions, mergers or acquisitions, or lack of standardization. Regular audits of the MPI database must be done to identify and resolve any overlaps and ensure data quality and integrity.
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) Master patient index - Clinfowiki1
質問 # 54
While reviewing a chart, a clinical documentation integrity practitioner (CDIP) needs to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes
1 and 2. Which coding reference should be used?
- A. Faye Brown's Coding Handbook
- B. AHA Coding Clinic for ICD-10-CM
- C. AMA CPT Assistant
- D. ICD-10-CM Official Guidelines for Coding and Reporting
正解：D
解説：
Explanation
The coding reference that should be used to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes 1 and 2 is the ICD-10-CM Official Guidelines for Coding and Reporting. This document provides the conventions and instructions for the proper use of the ICD-10-CM classification system, including the definitions and examples of the Includes Notes and Excludes Notes 1 and 2. The document is updated annually by the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), and is available online at 2. The other coding references listed are not specific to ICD-10-CM or do not contain the general rules for the Includes Notes and Excludes Notes 1 and 2.
References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 4
質問 # 55
The BEST place for the provider to document a query response is which of the following?
- A. The next progress note and the problem list
- B. The next progress note and all subsequent notes including the discharge summary
- C. An addendum to the history and physical
- D. The query form
正解：A
解説：
Explanation
The best place for the provider to document a query response is the next progress note and the problem list because this ensures that the query response is timely, consistent, and integrated into the health record. According to the AHIMA/ACDIS query practice brief1, the provider should document the query response in the health record as soon as possible after receiving the query, preferably in the next progress note.
The provider should also update the problem list to reflect any new or revised diagnoses resulting from the query response. This helps to maintain an accurate and comprehensive list of the patient's current and chronic conditions, which can facilitate continuity of care, quality reporting, and reimbursement. Documenting the query response in an addendum to the history and physical or only on the query form is not sufficient, as it may not capture the current status of the patient or be easily accessible to other providers or coders.
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
質問 # 56
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. Value and mission statements
- C. Diagnostic related groups and revenue cycle
- D. Benchmarks and case mix index
正解：B
解説：
Explanation
A CDI program's vision should reflect its purpose, values, and goals, and align with the organization's overall vision and mission. Value and mission statements help define the CDI program's role, scope, and objectives, and communicate them to stakeholders. Reporting and the use of technology are important tools for a CDI program, but they are not part of its vision. Benchmarks and case mix index are performance indicators that measure the CDI program's outcomes, but they do not reflect its vision. Diagnostic related groups and revenue cycle are aspects of reimbursement that may be affected by the CDI program, but they are not the primary focus of its vision.
質問 # 57
A query should include
- A. the impact on quality
- B. relevant clinical indicators
- C. the impact of reimbursement
- D. information from previous encounters
正解：B
解説：
Explanation
A query should include relevant clinical indicators from the health record that support the need for clarification and the query options. Clinical indicators are objective and measurable signs, symptoms, laboratory results, diagnostic test results, medications, treatments, and other documented findings that are related to a specific diagnosis or condition. Information from previous encounters, the impact on quality, and the impact of reimbursement are not appropriate to include in a query, as they may introduce bias, lead the provider, or imply a desired response.
質問 # 58
A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?
- A. Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
- B. Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient's morbid obesity was present on admission and add the diagnosis to future progress notes?
- C. Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)
- D. Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
正解：C
解説：
Explanation
This is the most compliant query based on the most recent AHIMA/ACDIS query practice brief because it is non-leading, non-suggestive, and provides multiple options for the physician to choose from. It also does not imply any financial or quality implications for adding a diagnosis associated with the BMI.
References: AHIMA/ACDIS. "Guidelines for Achieving a Compliant Query Practice (2019 Update)." Journal of AHIMA 90, no. 2 (February 2019): 20-29.
質問 # 59
......
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