AHIMA Updated CDIP Exam Questions and Answers by iona

According to the ACDIS Practice Brief, a query escalation policy should describe how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, the department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for the organization1. In this case, since two physicians have significantly lower query response rates than the target, the CDI physician advisor/champion should schedule individual meetings with each low-performing physician to provide feedback, education, and support. A group meeting with all physicians may not be effective or efficient, as it may not address the specific barriers or challenges faced by the low-performing physicians. A meeting with the chair of the gastroenterology department may be helpful, but it may not be sufficient to resolve the issue without direct communication with the low-performing physicians.

References:

• CDI Week 2020 Q&A: CDI and key performance indicators1

According to the CPT code description, 61154 is the appropriate code for a burr hole procedure for evacuation of a subdural hematoma. A burr hole is a small hole made in the skull with a surgical drill to access the brain or its coverings2. A subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, which are two of the three layers that cover the brain3. The evacuation of the hematoma involves removing the clot and relieving the pressure on the brain. The other codes are not applicable for this procedure because they describe different methods of access (twist drill hole) or different purposes (biopsy or puncture)4.

References:

• CDI Week 2020 Q&A: CDI and key performance indicators1
• Mayo Clinic: Burr hole2
• MedlinePlus: Subdural hematoma3
• CPT Code Book 20234

This query option is the most compliant based on the most recent AHIMA/ACDIS query practice brief because it meets the following criteria:

• It is based on clinical indicators in the health record that support a reasonable and logical connection between the conditions (femur fracture and osteoporosis).
• It is non-leading and non-suggestive, as it does not imply a specific answer or diagnosis, but rather asks for the provider’s opinion based on their clinical judgment.
• It is concise and clear, as it uses simple and direct language that avoids ambiguity or confusion.
• It is relevant and specific, as it addresses a clinical issue that has an impact on patient care, quality reporting, and/or reimbursement.
• It is consistent with clinical documentation integrity (CDI) standards and guidelines, as it follows the AHIMA/ACDIS query practice brief recommendations for query format, content, delivery, and documentation.

References:

• CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)
• CDIP® Exam Preparation Guide (https://my.ahima.org/store/product?id=67077)
• Guidelines for Achieving a Compliant Query Practice—2022 Update (https://acdis.org/resources/guidelines-achieving-compliant-query-practice%E2%80%942022-update)