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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

A) PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure
B) PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure
C) PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion
D) PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion

2. Proposed changes to the inpatient prospective payment system (IPPS) take effect on

A) January 1
B) October 1
C) April 1
D) July 1

3. Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner's role within the organization?

A) Mission
B) Review schedule
C) Milestones
D) Productivity standards

4. A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?

A) Bring together a team of physicians and informatics specialists
B) Alert senior leadership to the record documentation problem
C) Gather data on the incidence of inaccurate record documentation
D) Recommend the physicians to be involved in the project

5. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?

A) OCE
B) DRG
C) NOS
D) NEC

Solutions: