According to the AHIMA CDIP Exam Preparation Guide, a documentation integrity project is a systematic process of identifying, analyzing, and improving the quality and accuracy of clinical documentation in the health record 1 .  A documentation integrity project may have various purposes, such as enhancing patient safety, improving coding and reimbursement, or complying with regulatory standards 1 .  One of the common issues that may affect the quality and accuracy of clinical documentation is the indiscriminate use of electronic copy and paste of patient information in records by physicians 2 .  Copy and paste is a function that allows physicians to duplicate existing text in the record and paste it in a new destination, which may save time and effort, but also may introduce errors, inconsistencies, or redundancies in the documentation 2 . Therefore, to quantify the extent of the problem of copy and paste, the data that should be used is the incidence of redundancies in physician notes in a sample of hospital admissions.  Redundancies are repeated or unnecessary information that may clutter the record and impair its readability and reliability 3 . By measuring the frequency and types of redundancies in physician notes, the hospital can assess the impact of copy and paste on the documentation quality and identify areas for improvement. The other options are not correct because they do not directly measure the problem of copy and paste.  The percent of insurance billings denied due to lack of record documentation may reflect other issues besides copy and paste, such as incomplete or inaccurate documentation, coding errors, or payer policies 4 . The number of coder queries regarding inconsistent physician record documentation may indicate the presence of copy and paste, but it may also depend on other factors such as coder knowledge, query guidelines, or query response rate. The results of a survey of physicians that asks about documentation practices may provide some insight into the perceptions and attitudes of physicians regarding copy and paste, but it may not reflect the actual extent or impact of the problem on the documentation quality.  References :

CDIP Exam Preparation Guide - AHIMA

Auditing Copy and Paste - AHIMA

Copy/Paste: Prevalence, Problems, and Best Practices - AHIMA

Documentation Denials: How to Avoid Them - AAPC

[Q & A: Querying for clinical validation | ACDIS]

The clinical documentation integrity (CDI) manager should consult the Chief Medical Officer when developing query policy and procedures because the Chief Medical Officer is responsible for overseeing the quality and safety of patient care, ensuring compliance with regulatory and accreditation standards, and providing leadership and guidance to the medical staff. The Chief Medical Officer can help to establish the goals, scope, and authority of the CDI program, as well as to support the query process and promote provider education and engagement. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

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)

Educating physicians on severity of illness and risk of mortality is best accomplished by using case studies that demonstrate how documentation affects these indicators and how they impact patient care, quality outcomes, and reimbursement.

References : AHIMA. “CDIP Exam Preparation.” AHIMA Press, Chicago, IL, 2017: 97-98.

If the provider’s response to the query is different than what was expected by the CDIP, the CDIP should implement the department’s escalation process to ensure the validity and accuracy of the documentation and the coded data. The escalation process is a standardized procedure that involves a manager, committee, or other supervisory position to review and assess the query and the response, and to determine the appropriate next steps. The escalation process may include contacting the provider for clarification, education, or feedback; consulting with a physician advisor/champion or a coding auditor; or reporting the issue to a higher authority or regulatory body. The escalation process should be documented and communicated clearly and respectfully to all parties involved.

A. Record the query response as disagreed. This is not a sufficient action to take if the provider’s response to the query is different than what was expected by the CDIP. Recording the query response as disagreed may indicate a lack of agreement or consensus between the CDIP and the provider, but it does not address the underlying issue of documentation validity or accuracy. It may also create a negative impression or relationship between the CDIP and the provider.

B. Have a different CDI query the provider. This is not an appropriate action to take if the provider’s response to the query is different than what was expected by the CDIP. Having a different CDI query the provider may create confusion, inconsistency, or redundancy in the query process. It may also undermine the credibility or authority of the original CDI who queried the provider.

C. Revise the query and send it back to the provider. This is not a recommended action to take if the provider’s response to the query is different than what was expected by the CDIP. Revising the query and sending it back to the provider may imply that the CDI is dissatisfied or disagreeing with the provider’s response, which may be perceived as disrespectful or confrontational. It may also suggest that the CDI is trying to influence or coerce the provider to change their response, which may compromise the integrity and compliance of the query process.

References :

CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530

Guidelines for Achieving a Compliant Query Practice—2022 Update | ACDIS

Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

The Provider Query Toolkit: A Guide to Compliant Practices

According to the AHIMA CDIP Exam Preparation Guide, the adjusted case mix index (CMI) is a measure that demonstrates the relative severity and complexity of patients treated in a hospital, and is used to evaluate the financial impact of a hospital’s clinical documentation integrity (CDI) program 1 .  The adjusted CMI is calculated by multiplying the unadjusted CMI by a factor that accounts for the percentage of Medicare patients in the hospital 2 .  The higher the adjusted CMI, the higher the expected reimbursement per patient, and the more effective the CDI program is assumed to be 3 . The other options are not correct because they do not measure the severity and complexity of patients or the financial impact of CDI.  Hospital acquired conditions (HACs) are conditions that are not present on admission and are considered preventable by CMS, and may result in reduced reimbursement or penalties 4 . The program for evaluating payment patterns electronic report (PEPPER) is a report that provides hospital-specific data on potential overpayments or underpayments for certain services or diagnoses, and helps identify areas of risk or opportunity for improvement. Present on admission (POA) indicators are codes that indicate whether a condition was present at the time of admission or acquired during the hospital stay, and affect the assignment of DRGs and HACs.  References :

CDIP Exam Preparation Guide - AHIMA

Demystifying and communicating case-mix index - ACDIS

What is Case Mix Index? | The Importance of CMI

Hospital-Acquired Conditions (HACs) | CMS

[PEPPER Resources]

[Present on Admission Reporting Guidelines - CMS]

The factor that should be examined when developing documentation integrity projects is CC and MCC capture rates. CC stands for complication or comorbidity, and MCC stands for major complication or comorbidity. These are secondary diagnoses that affect the severity of illness (SOI) and risk of mortality (ROM) of the patient, as well as the reimbursement and quality measures of the hospital. CC and MCC capture rates measure how well the clinical documentation reflects the presence and impact of these conditions on the patient’s care.  Examining CC and MCC capture rates can help to identify documentation improvement opportunities, goals, strategies, and outcomes 4   References :  1 : https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf  4 : https://my.ahima.org/store/product?id=67077

The manager of HIM/Coding should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives because they are responsible for overseeing the coding and billing processes, ensuring compliance with coding guidelines and regulations, and collaborating with the CDI team to resolve coding and documentation discrepancies. The manager of HIM/Coding can also provide feedback on the CDI program’s impact on coding quality, accuracy, productivity, and reimbursement. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, examples from the hospital’s actual cases are the most effective for physicians in a hospital. Examples from the hospital’s actual cases can show how specific documentation elements, such as diagnoses, procedures, complications, comorbidities, and present on admission indicators, can affect the severity of illness and risk of mortality scores of the patients, as well as the hospital’s performance and reputation. Examples from the hospital’s actual cases can also provide feedback and education to the physicians on how to improve their documentation practices and standards.  References : : https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf : https://my.ahima.org/store/product?id=67077