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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?

A) Coders can rely on the laboratory results to confirm the patient's diagnosis
B) Any physician caring for the patient can correct inaccurate record notes
C) Errors are corrected by the clinician who authored the documentation
D) Amendments to record content must be co-signed by the attending physician

2. Hospital-acquired condition pay provisions apply only to

A) critical access hospitals
B) inpatient psychiatric hospitals
C) long-term acute care hospitals
D) inpatient prospective payment system hospitals

3. Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

A) Chief Financial Officer
B) Compliance Officer
C) Chief Medical Officer
D) CDI practitioner

4. A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?

A) Query for a diagnosis associated with the dietician's finding of malnutrition
B) Query for protein calorie malnutrition
C) Query for malignant pleural effusion
D) Query if the malignant pleural effusion is the reason for admission

5. A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for psuedomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would

A) meet medical necessity
B) not meet medical necessity
C) increase relative weight
D) not increase relative weight

Solutions: