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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate time frame. What should the CDIP do next?

A) Query wound care nurse
B) Query surgical consultant
C) Escalate issue to hospital administration
D) Escalate issue to medical staff leadership

2. Which entity has the following regulation?
A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

A) Centers for Medicare & Medicaid Services
B) Office of Inspector General
C) Office for Civil Rights
D) Office of the National Coordinator for Health Information Technology

3. The third quarter target concurrent physician query response rate for each physician in a hospital gastroenterology department was 80%. Nine physicians met or exceeded this metric; however, two physicians had third quarter concurrent physician query response rates of 19% and 64%. What is the best course of action for the clinical documentation integrity (CDI) physician advisor/champion?

A) Schedule a group meeting with all physicians
B) Schedule a meeting with the chair of the gastroenterology department
C) Schedule individual meetings with each physician
D) Schedule individual meetings with each low-performing physician

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

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

Solutions: