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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. What type of laboratory test is a creatinine test?

A) Chemistry
B) Hematology
C) Microbiology
D) Serology

2. The clinical documentation integrity practitioner (CDIP) performed a verbal query and then later neglected following up with the provider. How should the CDIP avoid a compliance risk for this follow up failure according to AHIMA's Guidelines for Achieving a Compliant Query Practice?

A) Complete the documentation immediately after the provider's response
B) Complete the documentation at the time of discussion or immediately following
C) Complete the documentation when there is a provider agreement
D) Complete the documentation at the end of the day when entering cases reviewed

3. Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?

A) Center for Improvement in Healthcare (CIHQ), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)
B) Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)
C) Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)
D) Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), Office of Inspector General (OIG)

4. A hospital noticed a 30% denial rate in Medicare claims due to lack of clinical documentation, placing the hospital at risk of multiple Medicare violations. What step should the clinical documentation integrity (CDI) manager take to help avoid future Medicare violations?
Collaborate with physician advisor/champion and revenue cycle manager
Instruct the billing department to write off claims with insufficient documentation

A) Assign pre-billing claim review duties to physicians
B) Prevent submission of claims for improper documentation

5. A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs:
BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia.
Aspiration precautions and IV Clindamycin
ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.

A) Simple pneumonia
B) Pneumonia, a sequela of CVA
C) Complex pneumonia
D) Aspiration pneumonia

Solutions: