AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient was admitted due to possible pneumonia. Chest x-ray was positive for infiltrate. The physician's documentation indicates that the patient continues to smoke cigarettes despite recommendations to quit. Patient also has a long-term history of chronic obstructive pulmonary disease (COPD) due to smoking. IV antibiotic was given for pneumonia along with oral Prednisone and Albuterol for COPD.
Discharge diagnoses:
1. Pneumonia
2. COPD
3. Current smoker
What is the correct diagnostic related group assignment?

A) DRG 202 Bronchitis and Asthma with CC/MCC
B) DRG 194 Simple Pneumonia and Pleurisy without CC/MCC
C) DRG 190 Chronic Obstructive Pulmonary Disease with MCC
D) DRG 204 Respiratory Signs and Symptoms

2. A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?

A) Read the nursing admission notes
B) Query the attending provider
C) Look for wound care documentation
D) Review the history and physical

3. A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?

A) Query for protein calorie malnutrition
B) Query for malignant pleural effusion
C) Query for a diagnosis associated with the dietician's finding of malnutrition
D) Query if the malignant pleural effusion is the reason for admission

4. The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?

A) Permit CDI practitioners to document physician responses in the charts
B) Have CDI manager teaming with coding supervisor to monitor physician responses
C) Allow physician to respond via e-mail
D) Require physicians to document responses in charts

5. A query should be generated when the documentation is

A) legible
B) consistent
C) conflicting
D) complete

Solutions: