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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 94-year-old female patient is admitted with altered mental status and inability to move the left side of her body. She is diagnosed with a cerebral vascular accident with left sided weakness. The patient is ambidextrous, but the physician does not specify the predominance of the affected side. The default code is

A) ambidextrous
B) preferred
C) dominant
D) non-dominant

2. A clinical documentation integrity (CDI) program that is compliant with regulations from the facility's payors results in

A) higher overall program cost
B) less risk from audits
C) need for more CDI staff
D) meeting external benchmarks

3. A clinical documentation integrity practitioner (CDIP) is reviewing an outpatient surgical chart. The patient underwent a laparoscopic appendectomy for acute gangrenous appendicitis. Which coding reference should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment classification (APC) reimbursement?

A) AHA Coding Clinic for ICD-10-CM/PCS
B) The Merck Manual
C) O AMA CPT Assistant
D) O ICD-10-CM/PCS Codebook

4. Which of the following is an appropriate first step to address physicians with low query response rates?

A) A meeting between the physician advisor/champion and the noncompliant physician
B) An educational session between the clinical documentation integrity practitioner (CDIP) and physician
C) The physician receives a suspension until query responses are improved
D) The medical staff review the physician's noncompliance to consider sanctions

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

Solutions: