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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The provider was queried because the patient met clinical criteria for acute hypoxic respiratory failure. The response to the query was different than what was expected by the clinical documentation integrity practitioner (CDIP). What should the CDIP do?

A) Revise the query and send it back to the provider
B) Implement the department's escalation process
C) Record the query response as disagreed
D) Have a different CDIP query the provider

2. The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

A) determine if only the treatment is documented and there is no diagnosis documented
B) watch for reportable conditions or conditions that are unambiguous or otherwise complete
C) identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
D) look for documented conditions that have well supported accompanying clinical criteria

3. Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?

A) Complete
B) Precise
C) Legible
D) Reliable

4. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?

A) NEC
B) NOS
C) OCE
D) DRG

5. A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?

A) AMA CPT Assistant
B) Physician's Desk Reference
C) The Merck Manual
D) Medical Dictionary

Solutions: