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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

2. A clinical documentation integrity practitioner (CDIP) is developing a plan to promote the CDI program throughout a major hospital. It is proving challenging to find support. What is a primary step for the CDIP?

A) Teach nursing staff about documentation integrity
B) Determine primary interests of an individual or department
C) Determine primary interests and needs as requested
D) Teach coding classes to the new physicians as needed

3. A 56-year-old male patient complains of feeling fatigued, has nausea & vomiting, swelling in both legs.
Patient has history of chronic kidney disease (CKD) stage III,
coronary artery disease (CAD) & hypertension (HTN). He is on Lisinopril. Vital signs: BP 160/80, P 84, R 20, T 100.OF. Labs: WBC 11.5 with 76% segs, GFR 45. CXR showed slight left lower lobe haziness. Patient was admitted for acute kidney injury (AKI) with acute tubular necrosis (ATN). He was scheduled for hemodialysis the next day. Two days after admission patient started coughing, fever of 101.8F, CXR showed left lower lobe infiltrate, possible pneumonia. Attending physician documented that patient has pneumonia and ordered Rocephin IV. How should the clinical documentation integrity practitioner (CDIP) interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC)?

A) Dr. Adair, please indicate if the patient's pneumonia was present on admission (POA) based on the initial chest x-ray?
B) Dr. Adair, in your clinical opinion, do you think that the patient's acute kidney injury with ATN exacerbated the patient's pneumonia?
C) No need to interact with the physician because it is obvious the pneumonia developed after admission, therefore, not present on admission.
D) No need to query the physician because even if the pneumonia is considered a HAC and cannot be used as an MCC, ATN is also an MCC.

4. In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?

A) The latest Medicare Provider and Analysis Review data
B) Explanations on how severity of illness and risk of mortality impact reimbursement
C) Emphasize the Medicare requirements for documentation
D) Examples from the hospital's actual cases

5. Which of the following is a clinical documentation element supporting a transbronchial biopsy?

A) Pathology report documenting alveolar tissue
B) Length of procedure
C) Pathology report documenting bronchial tissue
D) Hemoptysis

Solutions: