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| Section | Weight | Objectives |
|---|---|---|
| Clinical Coding Practice | 15–18% | - Diagnosis and procedure code assignment and sequencing - Coding fundamentals and guidelines application - DRG assignment and reimbursement concepts |
| Compliance | - Audit readiness and documentation integrity standards - Regulatory compliance and ethical documentation practices | |
| CDI Metrics and Statistics | - Performance metrics and reporting - Quality and outcome measurement (SOI/ROM) | |
| Education and Leadership Development | 21–26% | - Provider education and interdisciplinary communication - CDI project development and physician engagement - CDI program leadership and organizational collaboration |
| Record Review and Document Clarification | 24–28% | - Post-discharge review and documentation validation - Clinical documentation review and gap identification - Provider query development and compliance |
1. A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side. The default code is
A) ambidextrous
B) non-dominant
C) dominant
D) preferred
2. A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101° Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents "right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis".
What is the proper sequencing of the principal and secondary diagnoses?
A) Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus
B) Right lower quadrant abdominal pain, fever, vomiting, leukocytosis
C) Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus
D) Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis
3. 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) Replica
B) Clone
C) Overlap
D) Facsimile
4. A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate time frame. What should the CDIP do next?
A) Query wound care nurse
B) Query surgical consultant
C) Escalate issue to medical staff leadership
D) Escalate issue to hospital administration
5. Which of the following individuals is the first line of escalation for an unanswered query?
A) Medical Director
B) CDI Steering Committee
C) HIM/Coding Manager
D) CDI Manager
Solutions:
| Question # 1 Answer: B | Question # 2 Answer: A | Question # 3 Answer: C | Question # 4 Answer: C | Question # 5 Answer: D |
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