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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient presents to the emergency department for evaluation after suffering a head injury during a fall. A traumatic subdural hematoma is found on MRI, and the patient is taken directly to the operating room for evacuation. The neurosurgeon performs a burr hole procedure for evacuation of the subdural hematoma. The clot is removed successfully, and the patient is transferred to recovery in stable condition. Which is the correct current procedural terminology (CPT) code assignment for the procedure performed?

A) 61105 Twist drill hole subdural/ventricular puncture
B) 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
C) 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma
D) 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion

2. A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?

A) Queries are limited to non-leading questions
B) Primary care physicians must answer written queries
C) Queries for illegible chart notes are unnecessary
D) Non-responses to written queries are grounds for discipline

3. Which of the following is used to measure the impact of a clinical documentation integrity (CDI) program on Centers for Medicare and Medicaid Services quality performance?

A) Severity of illness
B) Outcome measures
C) Case mix index
D) Risk of mortality

4. 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

5. Which of the following falls under the False Claims Act?

A) Missing charges
B) Unbundling services
C) Missing modifiers
D) Missing diagnosis codes

Solutions: