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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?

A) Physician advisor/champion involvement
B) Physician and CDIP interaction
C) Executive oversight
D) Coder and CDIP interaction

2. A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

A) Septicemia due to klebsiella pneumoniae
B) Sepsis with pneumonia due to klebsiella pneumoniae
C) Sepsis with respiratory failure due to pneumonia
D) Severe sepsis with pneumonia due to klebsiella pneumoniae

3. Which of the following is an example of a hospital-acquired condition when not present on admission?

A) Iatrogenic pneumothorax with venous catheterization
B) Pressure ulcer stage III
C) Iatrogenic pneumothorax with lung biopsy
D) Pressure ulcer stage II

4. Several physicians at a local hospital are having difficulty providing adequate documentation on patients admitted with a diagnosis of pneumonia with or without clinical indications of gram-negative pneumonia. Subsequently, clinical documentation integrity practitioners (CDIPs) are altering health records. Which policy and procedure should be developed to ensure compliant practice?

A) Accreditation standards
B) Quality improvement standards
C) Performance standards
D) Professional ethical standards

5. When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?

A) Consulting
B) Surgical
C) Credentialing
D) Admitting

Solutions: