AHIMA Certified Documentation Integrity Practitioner

What is the primary goal of a clinical documentation integrity (CDI) program?

• APrevent every denial by obtaining additional diagnosis codes
• BSelect the diagnoses that produce the highest payment
• CRepresent the patient's actual conditions and care accurately
• DIncrease query volume even when the record needs no clarification

What is the MS-DRG (Medicare Severity Diagnosis Related Group) system?

• AA risk model assigning outpatient Medicare Advantage HCC scores
• BA survey assigning the hospital's overall quality star rating
• CA system determining only physician professional-fee payment
• DA classification grouping inpatient stays for Medicare prospective payment

What is a physician query in the context of CDI?

• AA notice that a diagnosis will be removed without clarification
• BA request to document a predetermined higher-paying diagnosis
• CA communication seeking clinically supported documentation clarification
• DAn instruction allowing the coder to replace the provider's diagnosis

In FY2027 MS-DRG v44, which secondary diagnosis code is listed as a CC before applicable exclusions?

• AN17.9: Acute kidney failure, unspecified
• BE11.9: Type 2 diabetes without complications
• CJ30.2: Other seasonal allergic rhinitis
• DI10: Essential hypertension

What are the characteristics of a compliant physician query?

• AUse relevant clinical evidence and preserve independent provider judgment
• BRequire multiple choice even when another compliant format fits better
• CInclude unsupported diagnoses to make the response list longer
• DEmphasize the diagnosis with the greatest financial effect

What is the difference between severity of illness (SOI) and risk of mortality (ROM) in clinical documentation?

• ASOI describes illness severity; ROM describes mortality risk
• BSOI is the number of codes; ROM is the number of procedures
• CSOI determines only payment; ROM determines only discharge timing
• DSOI is the probability of death; ROM is the extent of physiologic impairment

What is the principal diagnosis in an inpatient setting?

• AThe condition established after study as chiefly responsible for the admission
• BThe first suspected diagnosis entered before evaluation is completed
• CThe diagnosis producing the highest DRG weight among all conditions
• DThe condition with the greatest resource cost, regardless of admission reason

Which clinical indicator would support a query for sepsis documentation?

• AA positive culture without review of the clinical course
• BInfection with an acute organ-function change needing clinical clarification
• CAn isolated elevated heart rate after uncomplicated exercise
• DAntibiotic use without review of its indication or other findings

What is the impact of an MCC (Major Complication or Comorbidity) on DRG assignment?

• AAn excluded MCC remains a severity driver in the same claim
• BAny MCC necessarily changes every inpatient claim's DRG
• CAn eligible MCC may affect the severity tier when full grouping logic allows it
• DClinical seriousness alone determines the MCC effect on a claim

What is the difference between a concurrent and retrospective CDI review?

• ABoth terms prohibit clarification after the patient has left the hospital
• BConcurrent review is after discharge; retrospective review is during the encounter
• CConcurrent review is during the encounter; retrospective review follows it
• DBoth terms mean review limited to the final submitted insurance claim

In FY2027 MS-DRG v44, which code is listed as an MCC before applicable exclusions?

• AE44.0: Moderate protein-calorie malnutrition
• BI10: Essential hypertension
• CN17.9: Acute kidney failure, unspecified
• DE43: Unspecified severe protein-calorie malnutrition

What is the ACDIS (Association of Clinical Documentation Integrity Specialists)?

• AA professional association providing CDI education and resources
• BA hospital accreditor determining all Conditions of Participation
• CA payer replacing the official ICD-10-CM coding guidelines
• DA federal agency issuing mandatory diagnosis-code regulations

What clinical indicators support documentation of acute respiratory failure?

• AA significant change in gas exchange and respiratory support needing clarification
• BRoutine postoperative ventilation treated as proof of a new diagnosis
• COne oxygen-flow value interpreted without baseline status or assessment
• DStable baseline oxygen use without a new clinical concern

What is a 'leading query' and why is it considered non-compliant?

• AIt includes a supported diagnosis among other reasonable alternatives
• BIt offers neutral supported alternatives for the provider to assess
• CIt steers the provider toward a preferred response
• DIt requests clarification after discharge rather than during the stay

What is the Present on Admission (POA) indicator?

• AWhether the provider selected a diagnosis with a higher severity tier
• BWhether a diagnosis was entered before the claim was submitted
• CWhether the condition was present at the inpatient admission order
• DWhether the condition appeared before the discharge summary was signed

How does the Case Mix Index (CMI) relate to CDI?

• AA higher CMI independently proves better patient care outcomes
• BCDI can change the nationally published weight for a selected DRG
• CAccurate documentation supports the appropriate assigned DRG and CMI
• DEvery answered query increases the hospital's case-mix index

What is the role of a CDI specialist in the query process?

• AIdentify a supported documentation gap and seek neutral clarification
• BOverride a provider's diagnostic statement using a preferred threshold
• CRecord the missing diagnosis directly as though treating the patient
• DSelect the desired diagnosis based on the largest payment increase

What clinical indicators support a query for protein-calorie malnutrition?

• AA low BMI treated as sufficient proof of the malnutrition severity category
• BOne laboratory abnormality interpreted without a nutrition assessment
• CAn isolated low albumin treated as proof of severe malnutrition
• DNutrition assessment findings including intake, weight change, and muscle or fat loss

What is the difference between a CC (Complication/Comorbidity) and an MCC (Major Complication/Comorbidity)?

• AThey determine final payment without other claim inputs
• BThey divide medical diagnoses from diagnoses associated with surgery
• CThey indicate whether a condition began before or after admission
• DThey are different code-level severity designations used in MS-DRG grouping

What is the CMS Hospital-Acquired Condition (HAC) Reduction Program?

• AA guarantee that improved documentation prevents every payment penalty
• BA claim rule removing every diagnosis that developed after admission
• CA hospital-level payment reduction for specified poor HAC performance
• DA requirement to recode every POA-N condition as a complication

What is a documentation template and how does it support CDI?

• AInsert a predetermined diagnosis when a laboratory threshold is crossed
• BPrompt relevant clinical details while allowing individualized documentation
• CReplace the need to assess whether a diagnosis actually fits the patient
• DCarry forward previous diagnoses without checking their current relevance

When reviewing a record for heart failure documentation, what specificity should a CDI specialist look for?

• AInfer acute heart failure solely from administration of a diuretic
• BInfer the heart-failure type directly from ejection fraction alone
• CClarify supported type and acuity when the record leaves a meaningful gap
• DRequire a NYHA class as a mandatory field for every heart-failure code

What is the ICD-10-CM Official Guidelines for Coding and Reporting?

• AOfficial rules supplementing ICD-10-CM conventions and instructions
• BA clinical protocol defining the treatment of every diagnosis
• CA payer checklist replacing the official Index and Tabular List
• DA local hospital policy overriding the classification's instructions