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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

2. A hospital is conducting a documentation integrity project for the purpose of reducing indiscriminate use of electronic copy and paste of patient information in records by physicians. Which data should be used to quantify the extent of the problem?

A) Results of a survey of physicians that asks about documentation practices
B) Number of coder queries regarding inconsistent physician record documentation
C) Percent of insurance billings denied due to lack of record documentation
D) Incidence of redundancies in physician notes in a sample of hospital admissions

3. The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?

A) Encourage physician-nurse cooperation
B) Expand use of coding queries by CDI team
C) Add a physician advisor/champion to the CDI team
D) Alter the physician documentation requirements

4. Tracking denials within the clinical documentation integrity program is important to

A) determine coding inaccuracies and educate as necessary
B) identify documentation improvement opportunities and educate as necessary
C) confirm reimbursement was appropriate
D) file a timely appeal if the medical center disagrees with the RAC findings

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

Solutions: