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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. An organization dealing with staffing shortages has adopted a policy requiring clinical documentation integrity practitioner (CDIP) to stop reviewing any record after a major complication or co-morbidity is found. What is the unintended consequence of this?

A) Decrease in severity of illness and risk of mortality
B) Reduced risk of clinical denials
C) Increased number of records reviewed by each CDIP
D) Increase in case mix index

2. An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

A) 179 Respiratory Infections and Inflammations without CC/MCC
B) 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
C) 553 Bone Diseases and Arthropathies with MCC
D) 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC

3. The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate.
What might this indicate to the CDI manager?

A) The loss of a large volume of patients has impacted workflow
B) The program is successful because documentation has improved
C) The decrease in hospital census has caused a lack of query opportunities
D) CDI staff need education on identifying query opportunities

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

5. The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA's Guidelines for Achieving a Compliant Query Practice?

A) Complete the documentation immediately after the provider's response
B) Complete the documentation at the end of the day when entering cases reviewed
C) Complete the documentation when there is a provider agreement
D) Complete the documentation at the time of discussion or immediately following

Solutions: