CDIP Toolkit Exam | Questions with 100% Correct
Answers | Verified | Latest Update 2026
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Terms in this set (42)
recent drivers of CDI (p2) - MS-DRGs 2007 to reflect SOI/ROM
- POA indicators 2008
- Medicare Advantage/Part C (capitated, HCC)
- some payers moving to APR DRGs
- compliance reviews: RAC, Zone Program Integrity
Contractors, Medicaid Integ Contractors
purpose of CDI program (p2) to initiate concurrent and, as appropriate,
retrospective reviews of health records for
conflicting, incomplete, or nonspecific provider
documentation.
goal of CDI reviews (p2) to identify clinical indicators to ensure that all
diagnoses and procedures are supported by
ICD-9-CM codes.
key CDI stakeholders (p3) • HIM and coding departments
• Case management and utilization review
• Medical staff and physician leadership
• Executive leadership
• Patient financial services or billing
• Finance and revenue cycle
• Quality and risk management
• Nursing
• Compliance and ethics
, some examples of CDI goals (p4) • Obtain clinical documentation that captures the
patient severity of illness and risk of mortality
• Identify and clarify missing, conflicting, or
nonspecific physician documentation related to
diagnoses and procedures
• Support accurate diagnostic and procedural
coding, MS-DRG assignment, leading to
appropriate reimbursement
• Promote health record completion during the
patient's course of care, which promotes patient
safety
• Improve communication between physicians and
other members of the healthcare team
• Provide awareness and education
• Improve documentation to reflect quality and
outcome scores
• Improve coders' clinical knowledge
query (p4) the physician communication tool used
concurrently or retrospectively to obtain
documentation clarification.
Other terms synonymous with "query" include
clarification, clinical clarification, documentation
alert, and documentation clarification.
To support the request for clinical indicators and/or medical evidence that
documentation, CDI professionals prompted the request for clarification.
should provide... (p4)
An electronic query is... (p5) a process in which the physician can provide any
clarification or specificity on the case by creating
an electronic document that is linked to the
patient's EHR and made available as a permanent
part of the health record metadata.
Answers | Verified | Latest Update 2026
Save
Terms in this set (42)
recent drivers of CDI (p2) - MS-DRGs 2007 to reflect SOI/ROM
- POA indicators 2008
- Medicare Advantage/Part C (capitated, HCC)
- some payers moving to APR DRGs
- compliance reviews: RAC, Zone Program Integrity
Contractors, Medicaid Integ Contractors
purpose of CDI program (p2) to initiate concurrent and, as appropriate,
retrospective reviews of health records for
conflicting, incomplete, or nonspecific provider
documentation.
goal of CDI reviews (p2) to identify clinical indicators to ensure that all
diagnoses and procedures are supported by
ICD-9-CM codes.
key CDI stakeholders (p3) • HIM and coding departments
• Case management and utilization review
• Medical staff and physician leadership
• Executive leadership
• Patient financial services or billing
• Finance and revenue cycle
• Quality and risk management
• Nursing
• Compliance and ethics
, some examples of CDI goals (p4) • Obtain clinical documentation that captures the
patient severity of illness and risk of mortality
• Identify and clarify missing, conflicting, or
nonspecific physician documentation related to
diagnoses and procedures
• Support accurate diagnostic and procedural
coding, MS-DRG assignment, leading to
appropriate reimbursement
• Promote health record completion during the
patient's course of care, which promotes patient
safety
• Improve communication between physicians and
other members of the healthcare team
• Provide awareness and education
• Improve documentation to reflect quality and
outcome scores
• Improve coders' clinical knowledge
query (p4) the physician communication tool used
concurrently or retrospectively to obtain
documentation clarification.
Other terms synonymous with "query" include
clarification, clinical clarification, documentation
alert, and documentation clarification.
To support the request for clinical indicators and/or medical evidence that
documentation, CDI professionals prompted the request for clarification.
should provide... (p4)
An electronic query is... (p5) a process in which the physician can provide any
clarification or specificity on the case by creating
an electronic document that is linked to the
patient's EHR and made available as a permanent
part of the health record metadata.
