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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following is an example of a hospital-acquired condition when not present on admission?

A) Iatrogenic pneumothorax with lung biopsy
B) Pressure ulcer stage II
C) Pressure ulcer stage III
D) Iatrogenic pneumothorax with venous catheterization

2. A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is

A) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other.
B) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment.
C) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.
D) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.

3. A noncompliant query includes querying the provider regarding

A) acute blood loss anemia due to low hemoglobin treated with iron supplements
B) gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators
C) morbid obesity due to BMI of 40.9 documented on the history and physical
D) sepsis that was present on admission because sepsis was only documented in the discharge summary

4. Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?

A) Diagnostic related groups and revenue cycle
B) Reporting and the use of technology
C) Value and mission statements
D) Benchmarks and case mix index

5. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?

A) Coders can rely on the laboratory results to confirm the patient's diagnosis
B) Amendments to record content must be co-signed by the attending physician
C) Errors are corrected by the clinician who authored the documentation
D) Any physician caring for the patient can correct inaccurate record notes

Solutions: