AHIMA CDIP : Certified Documentation Integrity Practitioner

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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs:
BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia.
Aspiration precautions and IV Clindamycin
ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.

A) Complex pneumonia
B) Simple pneumonia
C) Aspiration pneumonia
D) Pneumonia, a sequela of CVA

2. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify for type of COPD such as severe asthma.
B) Query the physician to clarify if CXR result means patient has pneumonia.
C) Query the physician to clarify for clinical significance of the CXR results.
D) Query the physician to clarify if patient has acute COPD exacerbation.

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

4. A modifier may be used in CPT and/or HCPCS codes to indicate

A) a service or procedure resulted in expected outcomes
B) a service or procedure was performed by one provider
C) a service or procedure was performed in its entirety
D) a service or procedure was increased or reduced

5. Review the following query to determine if it is compliant:
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Dehydration
Hyponatremia
Hypernatremia
Chronic kidney disease (indicate stage)
Other (please specify)

A) Yes, query is compliant as it offers the minimum number of multiple-choice answers ..
B) Yes, query is compliant as it provides clinical indicators and several options for response.
C) No, query is noncompliant as it does not provide the option of "unable to determine".
D) No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.

Solutions: