CDIP AHMIA Practice Exam 2 Latest Update

CDIP AHMIA Practice Exam 2 Latest Update

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A ________ assists in educating medical staff members on documentation needed for accurate billing.a.Physician champion b.Compliance officer c.Chargemaster coordinator

d.Data monitor - CORRECT ANSWER: a Physician champion. The health information

manager must continuously promote complete, accurate, and timely documentation to ensure appropriate coding, billing, and reimbursement. This requires a close working relationship with the medical staff, perhaps through the use of a physician champion.Physician champions assist in educating medical staff members on documentation needed for accurate billing. The medical staff is more likely to listen to a peer than to a facility employee, especially when the topic is documentation needed to ensure appropriate reimbursement (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 381).

A 18 year-old male was admitted with exacerbation of asthma. To assign this diagnosis

for coding, the diagnosis should be clarified for:

a.Mild persistent b.Persistent persistent c.Moderate persistent d.Unspecified e.All of the above - CORRECT ANSWER: e All of the diagnoses listed could further describe the state of the patient's asthma. (CMS 2016b)

A 40-year-old female presented with a malignancy of the right ovary diagnoses 1 week ago. The patient also exhibited symptoms of confusion, headache, difficulty walking, 1 / 4

and blurred vision. Following extensive workup, it was determined the patient had a

malignancy of the cerebrum of the brain. The CDS should query to determine:

a.Primary site.b.Metastasis from and to.c.Secondary site.

d.POA indicator for the cerebrum malignancy. - CORRECT ANSWER: b Chapter 2 of

the ICD-10-CM contains the codes for most benign and all malignant neoplasms.Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary (metastatic) sites should also be determined

(CMS 2016).

A 42-year-old female underwent an emergent total hysterectomy due to tear of the uterus due to grapefruit-sized fibroid. The patient was transfused 3 units of packed red blood cells for anemia with a hemoglobin of 8.2. In this specific scenario, which query is

appropriate:

a.The CDI must query the cause of the fibroid b.Patient noted to have tear of the uterus with hemoglobin 8.2 and transfusion of 3 units RBCs. Is the patient's anemia due to blood loss? Yes or No c.Query not warranted

d.The CDI must ask an open ended query - CORRECT ANSWER: b The CDI can

perform a Yes and No query to determine if the anemia is due to blood loss (AHIMA 2013b, 50-53)

A 45 year-old female had a necrotic cellulitis with ulcer of her lower limb. The surgeon performed deep debridement of the area with scalpel and pulsatile irrigation. Additional information needed for accurate code assignment may be needed. Which of the following best describes the most appropriate areas that should be queried?a.Excisional or nonexcisional; location of the wound; depth or type of necrosis; cause of the condition, if known; stage of the ulcer; present on admission indicator b.Excisional or nonexcisional; depth or type of necrosis; cause of the condition, if known; stage of the ulcer; present on admission indicator c.Excisional or nonexcisional, location of the wound, depth/type of necrosis, present on admission indicator 2 / 4

d.No query needed - CORRECT ANSWER: a For the proper assignment of cellulitis,

ulcers, and debridement utilize Coding Clinic advice and ICD-10-PCS Guidelines.Documentation required by the physician/surgeon should include determination of excisional/nonexcisional removal of tissue, the most specific location of the wound, depth/type of necrosis such as muscle or bone, cause of the condition if known; i.e., diabetic, atherosclerotic, stage of the ulcer (I-IV), present on admission indicator determination (AHIMA 2015a).

A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory

laparoscopy and a ruptured appendix was discovered. The chief complaint was:

a.Ruptured appendix b.Exploratory laparoscopy c.Abdominal pain d.Cholelithiasis - CORRECT ANSWER: c The abdominal pain is the chief complaint and is the reason the patient presented/reason for visit (Shaw and Carter 2014; Fahrenholz and Russo 2013, 225).

A 68-year-old nursing home patient with status post CVA 2 weeks ago presents via the emergency department with a 1-day history of fever, and elevated blood sugars in the 180-210 range. The patient has stated they have significant pain of the right buttock since the previous admission. The patient has a history of diabetes, and is on long-term insulin. On physical exam, it is noted the patient had a fever of 101.3 with purulent

drainage with exposure of subcutaneous fat. This type of ulcer can be called a:

a.Stage I b.Stage II c.Stage III d.Stage IV - CORRECT ANSWER: c This is a Stage III ulcer; Full thickness skin loss.The National Pressure Ulcer Advisory Panel (NPUAP) has redefined the definition of a pressure ulcer and the stages of pressure ulcers. (AHA Fourth Quarter 2008, 132)

A CDI program should be governed by policies and procedures. These policies and procedures should be developed with the assistance of other departments affected by 3 / 4

clinical documentation, including compliance, case management, and what other department?a.Information systems b.Process improvement c.Health Information Management (HIM)

d.Finance - CORRECT ANSWER: c HIM These policies and procedures should be

developed with the assistance of other departments affected by clinical documentation, including compliance, case management, and HIM (AHIMA 2013b).

A CDI program should have ongoing monitoring to ensure CDI activities are being performed compliantly and accurately. This process is called.a.Quality Assurance Tool/Program b.CDI Monitoring Tool/Program c.CDI Checks and Balances Tool/Program d.This process is not required as long as knowledgeable staff is utilized - CORRECT ANSWER: a It is important to implement a Quality Assurance Audit Tool/Program to perform review of CDI functions and activities. It is important for a facility to have checks and balances in place to ensure the highest level of integrity as CDI programs mature.External audits will be scrutinizing health records closely for documentation, including those by RAC contractors. When developing a CDI program, a strong QA process can aid in achieving a successful and compliant program (AHIMA 2014a, 6).

A clinical documentation specialist (CDS) is employed at ABC hospital. She has been consistently having conversations with the hospitalists on what they should document on every patient that presents with fever and receives antibiotics. As director, you

should:

a.Review the AHIMA Query Brief with the CDS b.Review the escalation policy with the CDS c.Ensure all staff have the same proactive approach

d.No attention to this area is needed - CORRECT ANSWER: a Review the AHIMA

Query Brief with the CDS. Verbal queries should contain the same clinical indicators and follow the same format as written queries to ensure compliance and consistency in policy and process. Documentation of the verbal query may be condensed to reflect the stated information, but should identify the clinical indicators that support the query as

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