CDIP FINAL TEST 2026 QUESTIONS
WITH CORRECT ANSWERS GRADED
A+
◍ Cert.
Answer: Comprehensive error testing rate
◍ Patients with more medications or vascular lines, and longer lengths of stay,
were significantly more likely to have higher rates of documentation errors.
T/F?.
Answer: True
◍ When should a provider provide documentation for the best quality of
documentation?.
Answer: Right after caring for a patient
◍ What type of health record documentation should be top priority when
undertaking a CDI program?.
Answer: Inpatient Acute Care Health Record Documentation
◍ What are the key activities of a CDI program? (2).
Answer: Concurrent review and concurrent physician inquiry
◍ Cpt.
Answer: Current procedural terminology. The amas list of 5 digit codes used
to report outpatient hospital and Physicians Medical and surgical services.
CPT is used to report outpatient or Physician Office claims only and is
updated annually in January.
◍ What is a common function that has created a problem for data integrity of
the health record that healthcare organizations should establish compliance
guidance and well thought-out processes on?.
, Answer: Copy and Paste
◍ Hac.
Answer: Hospital-acquired conditions are defined as for discharges
occurring on or after October one 2008 ipps hospitals will not receive
additional payment for cases when one of the selected conditions is acquired
during hospitalization. In such cases payment will not be driven Higher by
the secondary diagnosis if it is identified as an h a c.
◍ When should a medical history and physical examination be completed?.
Answer: - No more than 30 days before or 24 hours after admission or
registration- Prior to surgery or procedure requiring anesthesia services
◍ In what timeframe should a final diagnosis of a health record and a
discharge summary be placed according to CMS conditions of
participation?.
Answer: Within 30 days following discharge
◍ Qio.
Answer: An organization responsible for determining whether care and
services provided were medically necessary and meet Professional
Standards regarding eligibility for reimbursement under Medicare and
Medicaid programs.
◍ Who does OIG used to administer Medicare A and B as well as to process
claims for services rendered?.
Answer: Medicare Administrative Contractors (MACs)
◍ Rom.
Answer: The anticipated likelihood of dying
◍ Soi.
Answer: Severity of illness supportive documentation reflecting objective
clinical indicators of a patient illness and the extent of physiologic
decompensation or loss of organ system function.
◍ Wbc.
, Answer: Normal range for WBC is 5 to 10 mm 3. The critical value for this
lab value is less than 2.5 or greater than 30.
◍ What is important about ventilation in the medical record?.
Answer: The timeframe of ventilation.
◍ What is a common type of malnutrition that the OIG has identified as an
over-used diagnosis resulting in overpayment under the MS-DRG system?.
Answer: Kwashiorkor Malnutrition
◍ Hgb.
Answer: Hemoglobin for males normal range is 14 through 18 for females
normal range is 12 through 16.
◍ Hct.
Answer: Hematocrit normal range for males is 42 to 52. Normal range for
females is 37 to 47.
◍ Four standards used in EBM (Evidence Based Medicine).
Answer: DesignTerminologyPerformanceProcedural
◍ 7 Quality Clinical Documentation Criteria.
Answer: LegibleReliablePreciseCompleteConsistentClearTimelyMake sure
to be able to identify examples of these*
◍ Each clinical criteria in a patient's health record must meet what?.
Answer: ALL seven of the criteria (gold standard) for clinical
documentation
◍ What might be required if a discharge summary is inconsistent with other
entries in the health record?.
Answer: A query
◍ What does the 2014 ICD-10-PCS guidelines state is essential to achieve
complete and accurate documentation?.
Answer: A joint effort between the healthcare provider and the coder
◍ When there is provider disagreement on a diagnosis in the record or the
diagnosis is unclear coders must always?.
WITH CORRECT ANSWERS GRADED
A+
◍ Cert.
Answer: Comprehensive error testing rate
◍ Patients with more medications or vascular lines, and longer lengths of stay,
were significantly more likely to have higher rates of documentation errors.
T/F?.
Answer: True
◍ When should a provider provide documentation for the best quality of
documentation?.
Answer: Right after caring for a patient
◍ What type of health record documentation should be top priority when
undertaking a CDI program?.
Answer: Inpatient Acute Care Health Record Documentation
◍ What are the key activities of a CDI program? (2).
Answer: Concurrent review and concurrent physician inquiry
◍ Cpt.
Answer: Current procedural terminology. The amas list of 5 digit codes used
to report outpatient hospital and Physicians Medical and surgical services.
CPT is used to report outpatient or Physician Office claims only and is
updated annually in January.
◍ What is a common function that has created a problem for data integrity of
the health record that healthcare organizations should establish compliance
guidance and well thought-out processes on?.
, Answer: Copy and Paste
◍ Hac.
Answer: Hospital-acquired conditions are defined as for discharges
occurring on or after October one 2008 ipps hospitals will not receive
additional payment for cases when one of the selected conditions is acquired
during hospitalization. In such cases payment will not be driven Higher by
the secondary diagnosis if it is identified as an h a c.
◍ When should a medical history and physical examination be completed?.
Answer: - No more than 30 days before or 24 hours after admission or
registration- Prior to surgery or procedure requiring anesthesia services
◍ In what timeframe should a final diagnosis of a health record and a
discharge summary be placed according to CMS conditions of
participation?.
Answer: Within 30 days following discharge
◍ Qio.
Answer: An organization responsible for determining whether care and
services provided were medically necessary and meet Professional
Standards regarding eligibility for reimbursement under Medicare and
Medicaid programs.
◍ Who does OIG used to administer Medicare A and B as well as to process
claims for services rendered?.
Answer: Medicare Administrative Contractors (MACs)
◍ Rom.
Answer: The anticipated likelihood of dying
◍ Soi.
Answer: Severity of illness supportive documentation reflecting objective
clinical indicators of a patient illness and the extent of physiologic
decompensation or loss of organ system function.
◍ Wbc.
, Answer: Normal range for WBC is 5 to 10 mm 3. The critical value for this
lab value is less than 2.5 or greater than 30.
◍ What is important about ventilation in the medical record?.
Answer: The timeframe of ventilation.
◍ What is a common type of malnutrition that the OIG has identified as an
over-used diagnosis resulting in overpayment under the MS-DRG system?.
Answer: Kwashiorkor Malnutrition
◍ Hgb.
Answer: Hemoglobin for males normal range is 14 through 18 for females
normal range is 12 through 16.
◍ Hct.
Answer: Hematocrit normal range for males is 42 to 52. Normal range for
females is 37 to 47.
◍ Four standards used in EBM (Evidence Based Medicine).
Answer: DesignTerminologyPerformanceProcedural
◍ 7 Quality Clinical Documentation Criteria.
Answer: LegibleReliablePreciseCompleteConsistentClearTimelyMake sure
to be able to identify examples of these*
◍ Each clinical criteria in a patient's health record must meet what?.
Answer: ALL seven of the criteria (gold standard) for clinical
documentation
◍ What might be required if a discharge summary is inconsistent with other
entries in the health record?.
Answer: A query
◍ What does the 2014 ICD-10-PCS guidelines state is essential to achieve
complete and accurate documentation?.
Answer: A joint effort between the healthcare provider and the coder
◍ When there is provider disagreement on a diagnosis in the record or the
diagnosis is unclear coders must always?.
