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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A query should be generated when the documentation is

A) complete
B) conflicting
C) legible
D) consistent

2. In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?

A) Examples from the hospital's actual cases
B) The latest Medicare Provider and Analysis Review data
C) Explanations on how severity of illness and risk of mortality impact reimbursement
D) Emphasize the Medicare requirements for documentation

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

4. A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

A) The associated diagnosis directly on the query form
B) The associated diagnosis and the clinical rationale in the progress notes
C) A cause-and-effect relationship between anemia and the underlying cause
D) That the blood loss was not clinically significant

5. The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?

A) Audit focused APR-DRGs and develop education plan for CDI team and physicians
B) Audit cases for missed diagnosis by the CDI practitioner to target in the education plan
C) Audit focused cases by physicians that have a higher SOI/ROM for education plan
D) Audit cases that have high SOI/ROM assigned by coders for education and follow-up

Solutions: