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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. 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 with tubular necrosis is supported
D) Query the physician to see if acute renal failure is clinically supported

2. A resident returns to the long-term care facility following hospital care for pneumonia. The physician's orders and progress note state "Continue IV antibiotics for pneumonia - 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia". Is it appropriate to code the pneumonia in this scenario?

A) Yes, J18.9, Pneumonia, unspecified organism, Z79.2 should be coded along with long term antibiotics
B) Yes, J18.9, Pneumonia, unspecified organism, should be coded until the condition is resolved
C) Yes J18.8, Pneumonia, other specified organism
D) No, since the patient needed a repeat x-ray, the condition does not clarify as a diagnosis

3. Which of the following individuals is the first line of escalation for an unanswered query?

A) CDI Manager
B) Medical Director
C) HIM/Coding Manager
D) CDI Steering Committee

4. Which of the following is a clinical documentation element supporting a transbronchial biopsy?

A) Hemoptysis
B) Pathology report documenting bronchial tissue
C) Pathology report documenting alveolar tissue
D) Length of procedure

5. A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?

A) No query is needed
B) Bring this case up in weekly Health Information Management meetings for further action
C) Take the case to physician advisor/champion to discuss further action
D) Query physician for POA

Solutions: