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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

A) query the provider to see if acute on chronic respiratory failure is supported by the health record
B) query the provider to see if chronic respiratory failure is supported by the health record
C) query the provider to see if respiratory insufficiency is supported by the health record
D) code the diagnoses of COPD exacerbation and chronic respiratory failure

2. An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

A) PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion
B) PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure
C) PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure
D) PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion

3. A clinical documentation integrity practitioner (CDIP) has been successful in getting physicians to respond to queries. However, when the CDIP poses a query to a specific doctor, there is no response at all. The CDIP has tried face-to-face conversations, calling, emails, texts, but still gets no response. What is the next step the CDIP should take?

A) Hold a meeting with the CDI director and the doctor to find out why the doctor is not responding to the queries
B) Elevate the issue to the physician advisor/champion after the CDI supervisor has reviewed the case and deemed the query appropriate
C) Warn the other CDIPs that the doctor is a non-responder and to forego querying
D) Report the doctor to the Vice President of Medical Affairs so the doctor understands the importance of clinical documentation

4. For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?

A) The name of the medication (aspirin) and the date it was last administered
B) The name of the medication (aspirin), the date, time and location where it was last administered
C) The name of the medication (aspirin), the date and time it was last administered
D) The name of the medication (aspirin), the date and location where it was last administered

5. The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program. The plan is to use case mix index (CMI) as a metric of CDI performance.
How will this metric be measured?

A) Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI
B) Month-to-month and focus on patient volumes to determine the raise the overall CMI
C) Over time with a focus on particular documentation improvement areas in addition to the overall CMI
D) Month-to-month to show CMI variability as a barometer of a specific month

Solutions: