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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

2. Which of the following criteria for clinical documentation means the content of the record is trustworthy, safe, and yielding the same result when repeated?

A) Precise
B) Legible
C) Reliable
D) Complete

3. Hospital policy states that physician responses to queries should be no longer than timely payer filing requirements. A physician responds to a query after the final bill has been submitted. How should administration respond in this situation?

A) Report the physician's delayed response to the Ethics and Compliance Committee
B) Maintain the original billing as supported by documentation in the medical record
C) Review the record to determine any potential data integrity impact and/or rebilling implications
D) Evaluate the payer's timeframe for billing and reasons for the physician's delayed response

4. Which factors are important to include when refocusing the primary vision of a clinical documentation integrity (CDI) program?

A) Diagnostic related groups and revenue cycle
B) Value and mission statements
C) Reporting and the use of technology
D) Benchmarks and case mix index

5. When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to

A) code the first condition listed
B) not code either diagnosis
C) query for clarification
D) code both diagnoses

Solutions: