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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Compliance | 4–8% | - Fraud and abuse prevention - Compliance monitoring and reporting - AHIMA standards and regulatory requirements - Legal and ethical documentation practices |
| Topic 2: Record Review & Document Clarification | 24–28% | - Compliance with query standards - Identify documentation gaps and specificity issues - POA, HAC, SOI, ROM clarification - Ethical provider query development - Query tracking and follow-up |
| Topic 3: Leadership | 17–22% | - Interdisciplinary collaboration - CDI program development and promotion - Policy and procedure creation - Provider engagement and communication |
| Topic 4: CDI Metrics & Statistics | 14–18% | - Query response and volume tracking - Benchmarking and reporting - DRG comparison and denial analysis - Quality audits and compliance monitoring |
| Topic 5: Research & Education | 11–15% | - Regulatory and guideline updates - Provider and staff education - Best practice research and implementation - Documentation improvement training materials |
| Topic 6: Clinical Coding Practice | 22–26% | - Coding software and reference resources - Payer requirements and reimbursement models - Principal and secondary diagnosis identification - DRG, CPT, and HCPCS code assignment - ICD-10-CM/PCS coding conventions and guidelines |
1. A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for psuedomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would
A) increase relative weight
B) not increase relative weight
C) not meet medical necessity
D) meet medical necessity
2. Which of the following may result in an incomplete health record deficiency being assigned to a provider?
A) A concurrent query
B) A retrospective query
C) An outstanding query
D) A quality query
3. A hospital administrator wants to initiate a clinical documentation integrity (CDI) program and has developed a steering committee to identify performance metrics. The CDI manager expects to use a case mix index as one of the metrics. Which other metric will need to be measured?
A) Assessment of CC/MCC capture rates
B) Assessment of APR-DRGs with capture of CC or MCC
C) Comparison of risk of mortality with diagnostic related group capture rates
D) Comparison of severity of illness with the CC capture rates
4. What policies should query professionals follow?
A) CMS's policies related to querying
B) Their healthcare entity's internal policies related to querying
C) AHIMA's policies related to querying
D) All healthcare entity's policies are the same
5. Which of the following should an organization consider when developing a query retention policy and procedure?
A) If the query is considered part of the health record
B) How the query will be formatted
C) What the escalation process will be
D) Who should be queried
Solutions:
| Question # 1 Answer: A | Question # 2 Answer: C | Question # 3 Answer: A | Question # 4 Answer: B | Question # 5 Answer: A |
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