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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A clinical documentation integrity practitioner (CDIP) is developing a plan to promote the CDI program throughout a major hospital. It is proving challenging to find support. What is a primary step for the CDIP?

A) Determine primary interests of an individual or department
B) Determine primary interests and needs as requested
C) Teach coding classes to the new physicians as needed
D) Teach nursing staff about documentation integrity

2. A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?

A) Medical Dictionary
B) Physician's Desk Reference
C) The Merck Manual
D) AMA CPT Assistant

3. While reviewing a chart, a clinical documentation integrity practitioner (CDIP) needs to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes
1 and 2. Which coding reference should be used?

A) Faye Brown's Coding Handbook
B) AHA Coding Clinic for ICD-10-CM
C) ICD-10-CM Official Guidelines for Coding and Reporting
D) AMA CPT Assistant

4. A clinical documentation integrity practitioner (CDIP) in an acute care hospital was asked to create new query templates for ICD-10 based on AHIMA and ACDIS guidelines. What should the multiple-choice query format include?

A) Impact on reimbursement
B) Clinically unsupported diagnosis
C) Clinically insignificant options
D) Clinically significant options

5. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify for clinical significance of the CXR results.
B) Query the physician to clarify if CXR result means patient has pneumonia.
C) Query the physician to clarify if patient has acute COPD exacerbation.
D) Query the physician to clarify for type of COPD such as severe asthma.

Solutions: