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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate.
What might this indicate to the CDI manager?

A) The decrease in hospital census has caused a lack of query opportunities
B) The loss of a large volume of patients has impacted workflow
C) The program is successful because documentation has improved
D) CDI staff need education on identifying query opportunities

2. The best approach in resolving unanswered queries is to

A) notify the coding team of the physician's unanswered query
B) notify the physician advisor/champion that the physician has not responded to the query
C) review the facility's query policies and procedures
D) contact the physician repeatedly until he/she responds to the query

3. AHIMA suggests which of the following for an organization to consider as physician response rate and agreement rate?

A) 70%/50%
B) 80%/80%
C) 80%/40%
D) 75%/75%

4. Several physicians at a local hospital are having difficulty providing adequate documentation on patients admitted with a diagnosis of pneumonia with or without clinical indications of gram-negative pneumonia. Subsequently, clinical documentation integrity practitioners (CDIPs) are altering health records. Which policy and procedure should be developed to ensure compliant practice?

A) Performance standards
B) Accreditation standards
C) Quality improvement standards
D) Professional ethical standards

5. A 100-year-old female presents to the emergency department with altered mental state and a 3-day history of productive cough, shortness of breath, and fever after a witnessed aspiration 3 days ago. The patient lives in custodial care at a nearby skilled nursing facility. Patient was treated with Augmentin at the facility without improvement. Exam is notable for Tc 38.9, blood pressure 142/78, respiratory rate 28, pulse 91. There is accessory muscle use with breathing.
Patient is moaning and disoriented but
otherwise the neurologic exam is nonfocal.
Labs notable for sodium 126, creatinine 0.5. white blood count 17.5, hemoglobin 13, platelet 200. venous blood gas 7.44/32/45/-3 Chest x-ray shows bilateral lower lobe infiltrates and dense right lower lobe consolidation.
Patient is placed on bilevel positive airway pressure and given vancomycin, pip/tazo, levofloxacin.
Discharge Diagnosis: health care associated pneumonia (HCAP), respiratory distress, altered mental status, low sodium Which list of diagnoses require a post-discharge query that will result in a more specific principal diagnosis with the highest level of severity of illness and risk of mortality?

A) Severe sepsis, hypernatremia, delirium, pneumonia
B) Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure
C) Coma, stroke, HCAP, hypernatremia
D) Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia

Solutions: