CDIP Free Practice Test

Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin- converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?

1. A. The query is unclear.
2. B. The query contains irrelevant information.
3. C. The query does not contain clinical indicators.
4. D. The query is leading.

Correct Answer: D
A leading query is one that suggests a specific diagnosis, condition, or treatment to the provider, or implies that a certain response is desired or expected. A leading query can compromise the integrity and accuracy of the documentation and the coded data, and may also raise compliance and ethical issues. A query should be non-leading, meaning that it presents the facts from the health record without bias or influence, and allows the provider to use their clinical judgment to determine the appropriate response.
The query in the question is leading because it implies that the patient??s CHF is systolic by asking a yes/no question that only offers one option. A non-leading query would ask an open-ended question that offers multiple options, such as ??What type of CHF does this patient have??? or ??Please specify the type of CHF: systolic, diastolic, or combined.?? 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

Which of the following indicates a noncompliant multiple-choice query? One that does NOT

1. A. include at least four options
2. B. allow the provider to add their own response
3. C. list options in alphabetical order
4. D. include the option of "unable to determine"

Correct Answer: A
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

Reviewing and analyzing physician query content on a regular basis

1. A. helps to calculate query response rate
2. B. aids in discussion between physician and reviewer
3. C. assists in identifying gaps in skills and knowledge
4. D. facilitates physician data collection

Correct Answer: C
Reviewing and analyzing physician query content on a regular basis assists in identifying gaps in skills and knowledge of the clinical documentation integrity practitioners (CDIPs) and the providers. By evaluating the quality, accuracy, appropriateness, and effectiveness of the queries, the CDIPs can identify areas of improvement, education, and feedback for themselves and the providers. Reviewing and analyzing physician query content can also help to ensure compliance with industry standards and best practices, as well as to monitor query outcomes and trends2 References: 1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf 2: https://my.ahima.org/store/product?id=67077

The BEST place for the provider to document a query response is which of the following?

1. A. The query form
2. B. The next progress note and the problem list
3. C. The next progress note and all subsequent notes including the discharge summary
4. D. An addendum to the history and physical

Correct Answer: B
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

Based on the flowchart below, at what point might the clinical documentation integrity practitioner (CDIP) enlist the help of the physician advisor/champion?

1. A. D - No retrospective query opportunity identified
2. B. H - Physician fails to respond tocquery
3. C. C - Retrospective query opportunity identified
4. D. E - Physician agrees with query and documents in MR

Correct Answer: B