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最新的 AHIMA CDI CDIP 免費考試真題:

1. A noncompliant query includes querying the provider regarding

A) morbid obesity due to BMI of 40.9 documented on the history and physical
B) acute blood loss anemia due to low hemoglobin treated with iron supplements
C) sepsis that was present on admission because sepsis was only documented in the discharge summary
D) gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators

2. A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?

A) Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)
B) Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient's morbid obesity was present on admission and add the diagnosis to future progress notes?
C) Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
D) Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.

3. A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0°. On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to

A) query the provider to see if pseudomonas sepsis is supported by the health record
B) code pneumonia, unspecified
C) code pseudomonas pneumonia
D) query the provider to document the etiology of pneumonia

4. The key component of the auditing and monitoring process to ensure provider query response is to

A) review queries retrospectively to ensure that they are completed according to documented Policies and procedures
B) audit individual providers to indicate improvement in health record documentation
C) have a process in place for ongoing education and training of the staff involved in conducting provider queries
D) make sure that the language in the query is not leading or otherwise inappropriate

5. While reviewing a chart, a clinical documentation integrity practitioner (CDIP) needs to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes
1 and 2. Which coding reference should be used?

A) AMA CPT Assistant
B) AHA Coding Clinic for ICD-10-CM
C) Faye Brown's Coding Handbook
D) ICD-10-CM Official Guidelines for Coding and Reporting

問題與答案：