Chapter 38 — Quiz
26 questions: multiple choice and short answer, written in the style of the CPC and CCS exams where the material is exam-relevant. The answer key is in the collapsed block at the bottom. All dashboards, engine outputs, and evaluation figures are this book's constructed teaching figures; no benchmark or product performance is asserted.
1. Clinical documentation integrity is best described as the discipline of:
- A. Selecting the code that produces the correct payment for a documented service
- B. Making the record describe the patient accurately and completely, in language the classification systems can read
- C. Reviewing completed claims against a written standard after payment
- D. Ensuring that every chart is coded within the productivity standard
2. The single structural difference between a CDI review and an audit is:
- A. Who performs it
- B. Whether a payer is involved
- C. When it happens — CDI reads unfinished work that can still be completed by the person who made it
- D. Whether the result is reported to management
3. Short answer: give the one-sentence rule for which sections of a progress note may carry forward and which may not.
4. A documented negative is:
- A. A denial reason code indicating a non-covered service
- B. A sentence recording that something did not happen, which converts silence into evidence
- C. A negative laboratory result
- D. A query answered "no"
5. "No imaging guidance used" in the March 14 procedure note is load-bearing because it:
- A. Establishes medical necessity for the injection
- B. Supports the modifier 25 argument
- C. Excludes 20611 on the physician's own statement, confirming 20610
- D. Documents patient consent
6. An absence of any statement about imaging guidance differs from a documented negative because:
- A. There is no difference; both support the lower-valued code
- B. Silence proves nothing and must be asked about; a documented negative decides the code
- C. Silence supports the higher-valued code
- D. Only inpatient records require documented negatives
7. A working DRG is:
- A. The DRG on the submitted claim
- B. The DRG the record would group to as it stands mid-stay, used as a review tool and never as a bill
- C. The DRG the payer assigns on adjudication
- D. The DRG used to compute the case mix index
8. Concurrency matters most because a clarification obtained during the stay:
- A. Is worth more money
- B. Is a progress note rather than an addendum dated when it was made
- C. Does not have to be documented
- D. Can be entered by the coder
9. Short answer: name the four things a query must never do, per §38.3's markers, in the shortest form you can.
10. A query option list contains five clinically reasonable options, every one of which adds or specifies a condition. The query is:
- A. Compliant, because five options is more than enough
- B. Compliant, because each option is clinically reasonable
- C. Leading, because the record's most likely answer is not on the list with equal weight
- D. Compliant only in the inpatient setting
11. A verbal query is:
- A. Prohibited
- B. Permitted, and must be documented — who asked, whom, when, what was asked, what was answered
- C. Permitted, and needs no documentation because it is not a written record
- D. Permitted only in the outpatient setting
12. A physician answers a query and the coder assigns a code from the query form because the physician never documented the answer in the chart. This is:
- A. Acceptable if the query is retained
- B. Acceptable if the query is part of the legal health record
- C. Not acceptable — a code is never assigned from an answer that exists only on the query form
- D. Acceptable if a second coder concurs
13. Querying the same encounter a second time after receiving an answer the coder did not want is:
- A. Compliant if the second query is worded differently
- B. Compliant if new clinical evidence is cited
- C. Leading, regardless of wording
- D. Required by professional guidance
14. Short answer: state the hard limit Chapter 36 §36.11 established about what a query can and cannot do.
15. The two CDI metrics that corrupt a program when they become targets are:
- A. Review coverage and turnaround time
- B. Query rate and agreement rate
- C. Response rate and DRG change rate
- D. Case mix index and financial impact
16. A CDI program can become a leading program without sending a single non-compliant query, by:
- A. Wording queries suggestively
- B. Sending only the queries it expects to be answered its way
- C. Failing to retain queries
- D. Using verbal queries
17. Of the following, the one that is not defensible is:
- A. Prioritizing which records get reviewed by financial materiality
- B. Reviewing a random sample alongside a targeted worklist
- C. Deciding whether to send a clinically warranted query based on the likely direction of the answer
- D. Reporting adds and removals as separate lines
18. In the CAC pipeline, the step this chapter calls the most valuable and least discussed is:
- A. Ingestion
- B. Concept extraction
- C. Confidence scoring
- D. Presenting the code with the source text that produced it, highlighted in place
19. "Mother with colon cancer at 62" produces a coding error through which qualifier?
- A. Negation
- B. Experiencer
- C. Temporality
- D. Certainty
20. "Probable aspiration pneumonia" documented at discharge is coded as an established diagnosis:
- A. In every setting
- B. In no setting
- C. On an inpatient claim, but not in the outpatient setting
- D. Only with a query response
21. Short answer: state the structural reason an engine cannot flag the absence of a sentence nobody wrote — and the one thing software can do that looks like it.
22. The four properties that make a domain autonomously codable are:
- A. Volume, revenue, staffing, and payer mix
- B. A structured source document, a small code space, low variability, and fast unambiguous feedback
- C. Accuracy, speed, cost, and vendor support
- D. Inpatient status, Medicare volume, template use, and coder experience
23. An engine suggests 1,905 codes; 1,712 are supported by the record. The record supported 1,840 codes in total. Precision and recall are:
- A. 93.0% and 89.9%
- B. 89.9% and 93.0%
- C. 89.9% and 89.9%
- D. 93.0% and 93.0%
24. Between a missed code and an unsupported code that reaches a claim:
- A. The missed code is worse, because it always costs more money
- B. They are equivalent errors with equivalent consequences
- C. Both are real errors, but only the unsupported code creates False Claims Act exposure that compounds with volume and consistency
- D. Neither is an error if the engine assigned it
25. The driver of model drift that almost nobody monitors is:
- A. The annual code set updates
- B. A new documentation template
- C. A change in what counts as "supported" — a revised payer policy, coverage article, guideline, or edit — with no change to any note
- D. Turnover among coders
26. Short answer: name the four things this chapter says the human in the loop is actually for, and add the fifth that belongs to this chapter specifically.