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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Record Review & Document Clarification | - Review Clinical Records
| |
| Topic 2: CDI Metrics & Statistics | - Measure and Analyze CDI Performance
| |
| Topic 3: Clinical Coding Practice | 15–18% | - Coding Application and Resources
|
| Topic 4: Compliance | - Regulatory and Compliance Fundamentals
| |
| Topic 5: Education and Leadership Development | 21–26% | - Promote Documentation Integrity
|
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?
Correct Answer: B 🗳️
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A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?
Correct Answer: A 🗳️
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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?
Correct Answer: B 🗳️
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The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to
Correct Answer: A 🗳️
Which of the following falls under the False Claims Act?
Correct Answer: B 🗳️
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