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NO.42 Combination codes are used to classify two diagnoses, a diagnosis with a manifestation, or a diagnosis

that is an integral part of a disease process

with an associated complication

with an associated procedure

with a sequelae or late effect

Explanation
Combination codes are used to classify two diagnoses, a diagnosis with a manifestation, or a diagnosis with an associated complication. A complication is a condition that arises during the hospital stay that prolongs the length of stay by at least one day in approximately 75 percent of cases1. Complications may affect payment and severity of illness and risk of mortality classifications. Examples of combination codes that include a diagnosis with an associated complication are:
I50.23 Acute on chronic systolic (congestive) heart failure
K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding O34.211 Maternal care for incompetent cervix with cerclage, first trimester A diagnosis that is an integral part of a disease process is not a valid option for combination codes, because it does not represent a separate or additional condition that needs to be coded. For example, chest pain is an integral part of acute myocardial infarction and does not require a separate code.
A diagnosis with an associated procedure is not a valid option for combination codes, because procedures are coded separately from diagnoses using ICD-10-PCS codes. For example, appendicitis with appendectomy is not a combination code, but rather two codes: one for the diagnosis (K35.80 Acute appendicitis without perforation or gangrene) and one for the procedure (0DTJ4ZZ Resection of appendix, percutaneous endoscopic approach).
A diagnosis with a sequelae or late effect is not a valid option for combination codes, because sequelae or late effects are coded separately from the original condition using the appropriate code from category B90-B94 Sequelae of infectious and parasitic diseases or category I69 Sequelae of cerebrovascular disease, followed by the code for the specific condition2. For example, hemiplegia following cerebral infarction is not a combination code, but rather two codes: one for the sequelae (I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side) and one for the original condition (I63.9 Cerebral infarction, unspecified).
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 ICD-10-CM Official Guidelines for Coding and Reporting FY 2022 Identifying ICD-10 Combination Codes – Outsource Strategies International

NO.43 Which of the following sources provide external benchmarks to examine the effectiveness of a facility’s clinical documentation program?

Health Care Financing Administration

American Health Information Management Association

Agency for Healthcare Research and Quality

Medicare Provider Analysis and Review

NO.44 The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

look for documented conditions that have well supported accompanying clinical criteria

determine if only the treatment is documented and there is no diagnosis documented

watch for reportable conditions or conditions that are unambiguous or otherwise complete

identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis

NO.45 A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?

Look for wound care documentation

Read the nursing admission notes

Query the attending provider

Review the history and physical

NO.46 Which of the following is used to measure the impact of a clinical documentation integrity (CDI) program on Centers for Medicare and Medicaid Services quality performance?

Risk of mortality

Case mix index

Severity of illness

Outcome measures

NO.47 The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA’s Guidelines for Achieving a Compliant Query Practice?

Complete the documentation immediately after the provider’s response

Complete the documentation at the end of the day when entering cases reviewed

Complete the documentation when there is a provider agreement

Complete the documentation at the time of discussion or immediately following

NO.48 Which of these medical conditions would a clinical documentation integrity practitioner (CDIP) expect to be treated with Levophed?

Septic shock

Acute respiratory failure

Multiple sclerosis

Acute kidney failure

Explanation
Levophed is a brand name of norepinephrine, a medication that is similar to adrenaline and acts as a vasopressor, meaning that it constricts blood vessels and increases blood pressure. Levophed is indicated to raise blood pressure in adult patients with severe, acute hypotension (low blood pressure) that can occur with certain medical conditions or surgical procedures1. One of these conditions is septic shock, which is a life-threatening complication of sepsis, a systemic inflammatory response to infection. Septic shock is characterized by persistent hypotension despite adequate fluid resuscitation, along with signs of organ dysfunction and tissue hypoperfusion. Levophed is used as a first-line vasopressor agent in septic shock to restore adequate perfusion pressure and tissue oxygenation.
Acute respiratory failure, multiple sclerosis, and acute kidney failure are not indications for Levophed treatment. Acute respiratory failure is a condition in which the lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from the blood. It can be caused by various lung diseases, injuries, or infections. The treatment of acute respiratory failure depends on the underlying cause and the severity of the condition, but it may include oxygen therapy, mechanical ventilation, medications to treat infections or inflammation, or other supportive measures. Multiple sclerosis is a chronic autoimmune disease that affects the central nervous system, causing inflammation, demyelination, and axonal damage. The symptoms of multiple sclerosis vary depending on the location and extent of the nerve damage, but they may include vision problems, numbness, weakness, fatigue, cognitive impairment, or pain. The treatment of multiple sclerosis aims to reduce the frequency and severity of relapses, slow the progression of disability, and manage the symptoms. It may include immunomodulatory drugs, corticosteroids, symptomatic medications, physical therapy, or other interventions. Acute kidney failure is a condition in which the kidneys suddenly lose their ability to filter waste products and fluids from the blood. It can be caused by various factors that impair the blood flow to the kidneys, damage the kidney tissue, or block the urine output. The symptoms of acute kidney failure may include decreased urine output, fluid retention, nausea, confusion, or shortness of breath. The treatment of acute kidney failure depends on the underlying cause and the severity of the condition, but it may include fluid management, electrolyte replacement, dialysis, medications to treat infections or inflammation, or other supportive measures.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Levophed Uses, Side Effects & Warnings – Drugs.com Levophed (Norepinephrine Bitartrate): Uses, Dosage … – RxList Levarterenol, Levophed (norepinephrine) dosing … – Medscape
[Septic Shock: Practice Essentials … – Medscape Reference]
[Surviving Sepsis Campaign: International Guidelines for … – PubMed]
[Acute respiratory failure: MedlinePlus Medical Encyclopedia]
[Multiple sclerosis – Symptoms and causes – Mayo Clinic]
[Acute kidney failure – Symptoms and causes – Mayo Clinic]

NO.49 What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

Multiple-choice

Open-ended

Verbal

Yes/No

NO.50 When writing a compliant query, best practice is to

direct the physician to a specific diagnosis

include all relevant clinical indicators

use the term “possible” to describe a condition or diagnosis when uncertain if the diagnosis is present

use a yes/no query format for specificity of a diagnosis

NO.51 Which of the following diagnosis is MOST likely to trigger a second level review?

Malnutrition

Pneumonia

Heart failure

Acute kidney injury

NO.52 A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition. Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?

61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural

61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma

61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion

61105 Twist drill hole subdural/ventricular puncture

NO.53 A 75-year-old, diabetic patient with a history of osteoporosis, being treated with Fosamax, who sustained a femur fracture after falling down three stairs. The provider’s documentation indicates to admit the patient for a traumatic femur fracture and an orthopedics consult is pending. The clinical documentation integrity practitioner (CDIP) decides to query for a possible link between osteoporosis and the femur fracture. Which of the following is the most compliant query based on the most recent AHIMA/ACDIS query practice brief?

Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. In your medical opinion, is this fracture consistent with an osteoporotic pathological fracture?

Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please clarify the cause of the femur fracture in your next note and/or the discharge summary.

Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Could diabetes be a contributing factor in the femur fracture?

Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please document “femur fracture due to osteoporosis” in your next progress note to demonstrate a link between the two diagnoses.

NO.54 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

code pneumonia, unspecified

query the provider to see if pseudomonas sepsis is supported by the health record

query the provider to document the etiology of pneumonia

code pseudomonas pneumonia

NO.55 Which of the following is MOST likely to trigger a second-level review?

A procedure code that increases reimbursement

A diagnosis that impacts a quality-of-care measure

An account coded before the discharge summary is available

A record with multiple major complicating conditions (MCCs)

NO.56 A hospital administrator has hired a clinical documentation integrity (CDI) firm to improve its revenue objectives. The physicians object to this action. How should the firm collaborate with physicians to overcome their objections?

Create a vision statement that outlines the project objectives

Communicate the benefits of the CDI firm about the project

Hire a consultant to communicate the benefits to the physicians

Identify an influential physician advisor/champion to promote support

Explanation
A physician advisor/champion is a physician leader who supports and advocates for the CDI program and its objectives. A physician advisor/champion can help overcome the objections of other physicians by providing education, feedback, guidance, and mentorship on documentation best practices and their impact on revenue, quality, and patient care. A physician advisor/champion can also act as a liaison between the CDI firm and the medical staff, resolve conflicts or discrepancies in documentation, and foster a culture of collaboration and improvement. Physicians are more likely to trust and engage with their peers who understand their clinical perspective and challenges, rather than an external CDI firm that may be perceived as intrusive or disruptive.
A:Create a vision statement that outlines the project objectives. This is not sufficient to collaborate with physicians and overcome their objections. A vision statement is a general statement that describes the desired outcome of the project, but it does not address the specific concerns or questions that physicians may have about the CDI firm’s role, methods, or benefits.
B:Communicate the benefits of the CDI firm about the project. This is not enough to collaborate with physicians and overcome their objections. Communicating the benefits of the CDI firm may be informative, but it may not be persuasive or credible if it comes from the CDI firm itself, without any endorsement or support from a physician leader within the organization.
C: Hire a consultant to communicate the benefits to the physicians. This is not a good way to collaborate with physicians and overcome their objections. Hiring a consultant may add another layer of complexity and cost to the project, and it may not improve the trust or relationship between the CDI firm and the physicians. A consultant may also lack the clinical expertise or authority to influence the physicians’ behavior or attitude.
References:
CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530 Q&A: Defining roles for physician advisor/champion | ACDIS Q&A: The Role of the Physician Advisor in CDI | ACDIS The Role of a Physician Advisor – UASI Solutions PA/NP in Physician Champion / Advisor Role – ACDIS Forums

NO.57 Reviewing and analyzing physician query content on a regular basis

helps to calculate query response rate

aids in discussion between physician and reviewer

assists in identifying gaps in skills and knowledge

facilitates physician data collection

NO.58 Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital’s clinical documentation integrity (CDI) program?

Hospital acquired conditions

Program for evaluating payment patterns electronic report

Present on admission indicators

Adjusted case mix index

NO.59 For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?

The name of the medication (aspirin), the date and time it was last administered

The name of the medication (aspirin), the date, time and location where it was last administered

The name of the medication (aspirin) and the date it was last administered

The name of the medication (aspirin), the date and location where it was last administered

NO.60 Which of the following may result in an incomplete health record deficiency being assigned to a provider?

A quality query

A retrospective query

A concurrent query

An outstanding query

NO.61 Which of the following falls under the False Claims Act?

Missing charges

Unbundling services

Missing modifiers

Missing diagnosis codes

NO.62 A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?

No query is needed

Query physician for POA

Bring this case up in weekly Health Information Management meetings for further action

Take the case to physician advisor/champion to discuss further action

NO.63 A patient presents to the emergency room with acute shortness of breath. The patient has a history of lung cancer that has been treated previously with radiation and chemotherapy. The patient is intubated and placed on mechanical ventilation. A chest x-ray is remarkable for a pleural effusion. A thoracentesis is performed, and the cytology results show malignant cells. Diagnoses on discharge: Acute respiratory failure due to recurrence of small cell carcinoma and malignant pleural effusion. Which coding reference takes precedence for assigning the ICD-10-CM/PCS codes?

Conventions and instructions of the classification for ICD-10-CM/PCS

AMA CPT Assistant

AHA Coding Clinic for ICD-10-CM/PCS

ICD-10-CM Official Guidelines for Coding and Reporting

NO.64 Which of the following clinical documentation integrity (CDI) dashboard metrics is frequently used to help evaluate the credibility of CDI practitioner queries and the success of the CDI program?

CDI agreement rate

CDI query rate

Provider response rate

Provider agreement rate

NO.65 The correct coding for heart failure with preserved ejection fraction is

150.32 Chronic diastolic (congestive) heart failure

I50.20 Unspecified systolic (congestive) heart failure

I50.9 Heart failure, unspecified

I50.30 Unspecified diastolic (congestive) heart failure

NO.66 A patient falls off a ladder and undergoes a right femur procedure. Three weeks later, the patient returns to the hospital for removal of the external fixation device. The ICD-10-CM 7th character code value should indicate

subsequent

sequela

initial

aftercare

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