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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Based on the flowchart below, at what point might the clinical documentation integrity practitioner (CDIP) enlist the help of the physician advisor/champion?

A) D - No retrospective query opportunity identified
B) E - Physician agrees with query and documents in MR
C) H - Physician fails to respond tocquery
D) C - Retrospective query opportunity identified

2. The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?

A) Permit CDI practitioners to document physician responses in the charts
B) Require physicians to document responses in charts
C) Allow physician to respond via e-mail
D) Have CDI manager teaming with coding supervisor to monitor physician responses

3. A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

A) Septicemia due to klebsiella pneumoniae
B) Sepsis with pneumonia due to klebsiella pneumoniae
C) Severe sepsis with pneumonia due to klebsiella pneumoniae
D) Sepsis with respiratory failure due to pneumonia

4. Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?

A) Query the physician to see if acute renal failure with tubular necrosis is supported
B) Query the physician to see if acute renal failure is clinically supported
C) No query is needed because the patient was dehydrated
D) Code acute renal failure since symptoms are there and documented

5. Which of the following individuals is the first line of escalation for an unanswered query?

A) CDI Manager
B) CDI Steering Committee
C) HIM/Coding Manager
D) Medical Director

Solutions: