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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. 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) No need to interact with the physician because it is obvious the pneumonia developed after admission, therefore, not present on admission.
B) 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.
C) Dr. Adair, please indicate if the patient's pneumonia was present on admission (POA) based on the initial chest x-ray?
D) Dr. Adair, in your clinical opinion, do you think that the patient's acute kidney injury with ATN exacerbated the patient's pneumonia?

2. Which of the following may result in an incomplete health record deficiency being assigned to a provider?

A) A concurrent query
B) A retrospective query
C) A quality query
D) An outstanding query

3. When are concurrent queries initiated?

A) Before patient is admitted
B) While the patient is hospitalized
C) After discharge of the patient
D) After the health record has been coded

4. An increase in claim denials has prompted a clinical documentation integrity (CDI) manager to engage the CDI physician advisor/champion in an effort to avoid future denials. How does this strategy impact the goal?

A) The CDI manager will exclusively provide education.
B) Physicians will learn documentation integrity practices from peers.
C) Clinicians will not require documentation integrity education.
D) Physicians can manage the documentation integrity process.

5. A noncompliant query includes querying the provider regarding

A) acute blood loss anemia due to low hemoglobin treated with iron supplements
B) sepsis that was present on admission because sepsis was only documented in the discharge summary
C) morbid obesity due to BMI of 40.9 documented on the history and physical
D) gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators

Solutions: