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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A clinical documentation integrity practitioner (CDIP) is looking for clarity on whether a diagnosis has been
"ruled in" or "ruled out". Which type of query is the best option?

A) Multiple-choice
B) Yes/No
C) Open-ended
D) None

2. A 56-year-old male patient complains of feeling fatigued, has nausea & vomiting, swelling in both legs.
Patient has history of chronic kidney disease (CKD) stage III,
coronary artery disease (CAD) & hypertension (HTN). He is on Lisinopril. Vital signs: BP 160/80, P 84, R 20, T 100.OF. Labs: WBC 11.5 with 76% segs, GFR 45. CXR showed slight left lower lobe haziness. Patient was admitted for acute kidney injury (AKI) with acute tubular necrosis (ATN). He was scheduled for hemodialysis the next day. Two days after admission patient started coughing, fever of 101.8F, CXR showed left lower lobe infiltrate, possible pneumonia. Attending physician documented that patient has pneumonia and ordered Rocephin IV. How should the clinical documentation integrity practitioner (CDIP) interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC)?

A) Dr. Adair, please indicate if the patient's pneumonia was present on admission (POA) based on the initial chest x-ray?
B) No need to interact with the physician because it is obvious the pneumonia developed after admission, therefore, not present on admission.
C) No need to query the physician because even if the pneumonia is considered a HAC and cannot be used as an MCC, ATN is also an MCC.
D) Dr. Adair, in your clinical opinion, do you think that the patient's acute kidney injury with ATN exacerbated the patient's pneumonia?

3. Which of the following sources provide external benchmarks to examine the effectiveness of a facility's clinical documentation program?

A) Health Care Financing Administration
B) Medicare Provider Analysis and Review
C) American Health Information Management Association
D) Agency for Healthcare Research and Quality

4. Which of the following is an appropriate first step to address physicians with low query response rates?

A) The physician receives a suspension until query responses are improved
B) The medical staff review the physician's noncompliance to consider sanctions
C) An educational session between the clinical documentation integrity practitioner (CDIP) and physician
D) A meeting between the physician advisor/champion and the noncompliant physician

5. A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0°. On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to

A) query the provider to document the etiology of pneumonia
B) code pseudomonas pneumonia
C) code pneumonia, unspecified
D) query the provider to see if pseudomonas sepsis is supported by the health record

Solutions: