Clinical Documentation Improvement (CDI) Strategies and Best Practices, Exams of Management of Health Service

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CDI Clinical Documentation Improvement

2024 Exam Review Questions and Answers

100% Pass | Graded A+

David Mungai [Date] [Course title]

CDI Clinical Documentation

Improvement 2024 Exam Review

Questions and Answers 100% Pass |

Graded A+

What is a reason a physician documentation can be difficult to review? - Answer>> Illegible handwriting The best scientific data available for clinical documentation is also known as - Answer>> 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? - Answer>> 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? - Answer>> 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: - Answer>> Documentation What evidence supports the lack of high-quality clinical documentation in the medical field? - Answer>> 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? - Answer>> Physicians should include vaccination records

Which practitioners, along with coding professionals, are proficient at picking up deficiencies in clinical documentation yet must focus on giving care? - Answer>> Nurses Which healthcare setting requires high levels of proactivity from management and clinical teams to ensure accurate and timely clinical documentation? - Answer>> Outpatient Which item is not an inpatient healthcare setting? - Answer>> Emergency department High-quality clinical documentation is the basis for what standard?

• Answer>> Gold standard What allows the diagnostic, treatment, and response of information of the patient to be aggregated into a uniform data set? - Answer>> Coding What part of the health record, usually located at the end the document, provides a complete picture of the patient's diagnosis?
• Answer>> Impression and plan What description is an aspect of the coding professionals' job? - Answer>> 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? - Answer>> Severity-based DRG What is the ultimate goal of the installation of the POA indicator? - Answer>> 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? - Answer>> 24- Which form of documentation is the essence of the health record on which the coder relies? - Answer>> Progress notes A query is necessary when a conflict in documentation exists between an attending physician and which practitioner? - Answer>> Anesthesiologist What does the fifth digit "1" represent with regard to the myocardial infarction code? - Answer>> Current admission What is suggested as a requirement for reflection of current medical practices and supports worldwide epidemiology? - Answer>> New coding system A 3M study suggested that the reimbursement impact on the implementation of ICD-10-CM/PCS would be what? - Answer>> Minimal What is the estimated negative impact of the top 25 MS-DRGs mentioned in the text? - Answer>> 1.4 percent What is the first step required to determine the facility specific impact of ICD-10 implementation? - Answer>> Begin dual coding What is the principal tool used by CDI programs to enhance efficiency? - Answer>> Analytics

The ____________ is one of the key indicators used to monitor a successful CDI program. - Answer>> Capture rate What is one important reason for having a CDI vision statement?

• Answer>> It provides a purpose for the program Prior to creating a vision statement for clinical documentation and CDI, what is the first necessary step? - Answer>> 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? - Answer>> Oversight What committee is comprised of individuals responsible for day- to-day management and support for the CDI program? - Answer>> Operational What is the most essential role the oversight committee plays? - Answer>> Obtain and maintain support from the medical staff Which hospital leader should provide the initial announcement for the CDI program the organization installs? - Answer>> Chief executive officer When refreshing an existing CDI program, what is one of the recommendations when quality or mortality scores decline? - Answer>> 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? - Answer>> What media the organization will use to communicate it What is the key to success and sustainability of the CDI program?

• Answer>> Physician support The operational committee is responsible for which process on an ongoing basis? - Answer>> Queries for high-quality clinical documentation Which executive must be involved in designing communication of the clinical documentation program from the start? - Answer>> Physician executive What must happen in order to obtain ultimate success with regard to clinical documentation? - Answer>> Adopt a program structure that fits the organization The advent of the EHR has increased the amount of documentation based largely due to: - Answer>> Ease of entry What is the minimum recommended length of training in clinical documentation for the CDI physician leader? - Answer>> 40 hours When the CDI program encounters a problematic physician, who should control and resolve the situation? - Answer>> 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? - Answer>> Director of CDI department

Which CDI trainer should be well versed in clinical documentation principles, quality indicators, and coding and reimbursement methodologies? - Answer>> Nonphysician trainer Which type of physician is often top priority for CDI training and account for, on average, 60 percent of the hospital admissions? - Answer>> Hospitalist In the CAMP acronym, what does the M stand for? - Answer>> Mastering In the CAMP acronym, asking means: - Answer>> Asking for feedback from physician students at the right time A typical CAMP training program consists of: - Answer>> Four hours of training for physicians to learn core concepts The CDI staff training is recommended to be a three-part program. Which is one of the three parts? - Answer>> Program data collection and analysis What should be done after the entire training program is complete for CDI staff? - Answer>> Testing and self-evaluation Clinical documentation determines actual and perceived quality of care which makes it important to train CDI staff on what basics of Medicare? - Answer>> Quality indicators The health record review process and what other aspect allow for the highest level of quality in clinical documentation? - Answer>> Physician queries

What should the CDI program staff do after the majority of classroom basics have been discussed? - Answer>> Case review on the nursing units The CDI specialists are partnered with the CDI trainees to discuss which aspect of the record review process? - Answer>> Sources of query opportunities Which tool is used by the CDI program staff to generate reports using entered data elements? - Answer>> CDI Monitor What can the CDI program staff generate by training the documenting clinicians on the CDI basics? - Answer>> Clinically valid queries Who should be given high priority CDI training due to their partnership with physicians? - Answer>> Nurses practitioners It is vital to provide CDI training to anyone who performs _______. - Answer>> Documentation in clinical records There is currently no benchmark for this metric; each organization should determine it: - Answer>> Physician response rate Which is a primary reason for the demand for high-quality clinical documentation? - Answer>> Code assignment Clinical documentation policies and procedures should: - Answer>> Be created by and specifically for each organization Though the goal for concurrent documentation review should be 100 percent, which type of inpatient stay makes it hard for any meaningful review? - Answer>> One-day stays

Hospitals often track the physician response rate. What could a level lower than benchmark reflect? - Answer>> Lack of physician-hospital alignment In general, hospitals have higher quality scores when _____________. - Answer>> The majority of patients are grouped in the higher severity levels Which is the average DRG relative weight for inpatient cases and an indicator of average reimbursement per patient? - Answer>> Case mix index What term refers to the change in average reimbursement per patient that occurs when different types of patients are being admitted as compared to another period of time? - Answer>> Real patient mix change What occurs when a change in CMI occurs due to changes in documentation practice? - Answer>> CDI case mix change Higher quality clinical documentation is a primary contributor to a higher level of __________. - Answer>> Severity level accuracy Which is an important component of follow-up education? - Answer>> Testing A convenience sampling methodology implies: - Answer>> Selecting cases that are convenient to retrieve What type of testing is best taken post-training? - Answer>> Multiple choice What is one key component of a compliant CDI program? - Answer>> Documented, mandatory physician education

Detailed query documentation can be used to: - Answer>> Protect the hospital against claims from physicians about leading queries A comprehensive retrospective review should be conducted at least once a year of what aspect of the CDI program? - Answer>> All query opportunities Qualified individuals who are not involved in the day-to-day operations of the CDI program should conduct a____________? - Answer>> Retrospective record audit Which plan should be devised to respond to issues arising from the CDI compliance and operational audit process? - Answer>> Corrective action plan What is the goal of the CDI compliance review? - Answer>> Compliant query generation and physician responses When conducting an audit review of records for CDI, what would the minimum number of records to pull be? - Answer>> 30 Generally, initial CDI implementation programs should: - Answer>> Plan expansion in small steps Why is it important to obtain support of the medical staff when creating a physician report card? - Answer>> It could harm hospital-physician relationships The initial focus of a CDI implementation program in one patient care setting is often due to what reason? - Answer>> Targeting one area is less risky

The CDI staff might create a feedback loop with which department to prevent disgruntled physicians from filing claims against them?

• Answer>> Compliance CDI staff members must work directly with this department to obtain data about retrospective physician queries. - Answer>> Health information management Organizations that design their systems around this have been proven to be more successful. - Answer>> Patients A future goal for any CDI program should be to implement: - Answer>> Six Sigma What stage of EHR transformation does the SEHR system benchmark with a mixture of discreet data, document imaging, and medical imaging? - Answer>> Stage 7 This stage shows the strongest correlation between higher quality indicators and the hospitals EHR scores: - Answer>> Stage 4 Which stage are vital signs and flow sheets required as electronic documentation? - Answer>> Stage 3 What is one of the key benefits of a Stage 7 transformation? - Answer>> Makes health information available to the patient What is the earliest stage in which the HCO fully implements the closed-loop medication administration environment in at least one patient care area? - Answer>> Stage 5 Which is one of the five rights of medication administration? - Answer>> Time

What stage of transformation does full closed-loop medication administration implementation in at least one patient care area represent? - Answer>> Stage 5 Stage 6 transformation includes implementing full physician documentation and what other item in at least one patient care area of the hospital? - Answer>> Charting using structured templates What median stage have most acute care facilities reached? - Answer>> Stage 3 Why is it essential for members of the compliance team to be involved in the entire EHR implementation process? - Answer>> To monitor cut and paste documentation CDI teams can use the time saved by using NLP applications to: - Answer>> Expand the program to include other payers The first phase in the history of NLP is known for which technology? - Answer>> Machine translation Which technology provides mined information from a narrative content that combines with structured EHR data to identify deficiencies in clinical documentation? - Answer>> Real-time deficiency tracking Collaborative intelligence offers solutions for improving clinical documentation such as: - Answer>> Real-time documentation improvement Built-in EHR prompts such as "type and acuity" of CHF are an example of using____________ to improve the clinical record. - Answer>> Structured data elements

The MDT approach provides a beneficial advantage of _____________. - Answer>> Increased exposure to different disciplines Which member(s) of the medical staff is (are) usually assigned to the CDI program and reports directly to the medical staff leadership? - Answer>> Physician advisor Which department of the hospital is responsible for providing the CDI team with CMI and DRG payment analytics? - Answer>> Revenue integrity The utilization review process gathers authorizations for continued stays and is provided by which department? - Answer>> Care management What activity can help break down natural barriers and create a rich cooperative environment in which CDI thrives? - Answer>> Building team cohesiveness Why do most organizations implement CDI in inpatient areas first? - Answer>> The amount of documentation per patient What is the fundamental difference in the CDI implementation process between inpatient and outpatient settings? - Answer>> Examples used to teach physicians Which does documentation for services rendered, such as patient health records and physician orders, support? - Answer>> Medical necessity What is a standardized methodology for the inpatient setting but not for the outpatient setting? - Answer>> Concurrent review

What is an excellent tool for outpatient CDI training? - Answer>> Web-based training In the diagnostic laboratory setting, what is the challenge for physicians ordering tests prior to rendering services? - Answer>> Accurate detailed documentation Outpatient CDI functions in the ED can be woven into which position's duties? - Answer>> Case manager Which type of medical visit presents the highest level of volume? - Answer>> Office or clinical visits What is the primary reason for implementing a service-based CDI strategy? - Answer>> Quality of care What aspect of CDI remains the same regardless of the practitioner or patient setting involved? - Answer>> Principles What can the CDI team do to improve communication with difficult staff members? - Answer>> Critical thinking The use of critical thinking allows for confidence through success, independent action, and which item? - Answer>> Collaboration Why is critical thinking necessary in the current healthcare setting? - Answer>> Technological development Which item increases complexity with the query process? - Answer>> Decreased face-to-face communication How have complex barriers burdened the query process? - Answer>> Multi-network tracking