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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Reviewing and analyzing physician query content on a regular basis

A) assists in identifying gaps in skills and knowledge
B) facilitates physician data collection
C) helps to calculate query response rate
D) aids in discussion between physician and reviewer

2. Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?

A) No query is needed because the patient was dehydrated
B) Code acute renal failure since symptoms are there and documented
C) Query the physician to see if acute renal failure is clinically supported
D) Query the physician to see if acute renal failure with tubular necrosis is supported

3. A query should be generated when documentation contains a

A) postoperative hospital-acquired condition
B) diagnosis without clinical validation
C) principal diagnosis without an MCC
D) problem list with symptoms related to the chief complaint

4. A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped. Which policy should the hospital follow to avoid a compliance risk?

A) A rebilling is permissible when queries are answered after the initial bill.
B) A post-bill query rarely occurs as a result of an audit or other internal monitor.
C) A second bill should not be submitted when the first bill was incomplete.
D) A post bill query is not appropriate when an error is found after an audit.

5. The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?

A) Audit focused APR-DRGs and develop education plan for CDI team and physicians
B) Audit cases for missed diagnosis by the CDI practitioner to target in the education plan
C) Audit focused cases by physicians that have a higher SOI/ROM for education plan
D) Audit cases that have high SOI/ROM assigned by coders for education and follow-up

Solutions: