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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following sources provide external benchmarks to examine the effectiveness of a facility's clinical documentation program?

A) Agency for Healthcare Research and Quality
B) Health Care Financing Administration
C) American Health Information Management Association
D) Medicare Provider Analysis and Review

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

3. A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0°. On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to

A) code pneumonia, unspecified
B) query the provider to see if pseudomonas sepsis is supported by the health record
C) query the provider to document the etiology of pneumonia
D) code pseudomonas pneumonia

4. The key component of the auditing and monitoring process to ensure provider query response is to

A) make sure that the language in the query is not leading or otherwise inappropriate
B) have a process in place for ongoing education and training of the staff involved in conducting provider queries
C) audit individual providers to indicate improvement in health record documentation
D) review queries retrospectively to ensure that they are completed according to documented Policies and procedures

5. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?

A) Errors are corrected by the clinician who authored the documentation
B) Any physician caring for the patient can correct inaccurate record notes
C) Amendments to record content must be co-signed by the attending physician
D) Coders can rely on the laboratory results to confirm the patient's diagnosis

Solutions: