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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. 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) identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
C) look for documented conditions that have well supported accompanying clinical criteria
D) watch for reportable conditions or conditions that are unambiguous or otherwise complete

2. An 86-year-old female is brought to the emergency department by her daughter. The patient complains of feeling tired, weak and excessive sleeping. The patient's daughter comments that patient's mental condition has not been the same. Lab results are unremarkable except for a sodium level of 119, a BUN of 22, and a creatinine of 1.35. The patient receives normal saline IV infusing at 100 cc/hr. The admitting diagnosis is weakness, altered mental status and dehydration. Which of the following queries is presented in an ethical manner thus avoiding potential fraud and/or compliance issues?

A) Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr, please clarify the clinical significance of the lab result.
B) Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr. Is the altered mental status related to the sodium of 119?
C) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, is this clinically significant? If so, please document a corresponding diagnosis related to this lab result.
D) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, does patient have hyponatremia?

3. Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?

A) The query is unclear.
B) The query contains irrelevant information.
C) The query is leading.
D) The query does not contain clinical indicators.

4. The ultimate purpose of clinical documentation integrity (CDI) expansion and growth is to

A) provide community education to healthcare consumers
B) create synergy between clinical education and CDI principles
C) promote CDI functions so that physicians view the CDI staff as value-added service
D) show a direct relationship between clinical documentation and quality patient care

5. A clinical documentation integrity practitioner (CDIP) is looking for clarity on whether a diagnosis has been
"ruled in" or "ruled out". Which type of query is the best option?

A) None
B) Open-ended
C) Multiple-choice
D) Yes/No

Solutions: