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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?

A) Alter the physician documentation requirements
B) Encourage physician-nurse cooperation
C) Expand use of coding queries by CDI team
D) Add a physician advisor/champion to the CDI team

2. While reviewing a chart, a clinical documentation integrity practitioner (CDIP) needs to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes
1 and 2. Which coding reference should be used?

A) AHA Coding Clinic for ICD-10-CM
B) Faye Brown's Coding Handbook
C) AMA CPT Assistant
D) ICD-10-CM Official Guidelines for Coding and Reporting

3. A clinical documentation integrity practitioner (CDIP) is reviewing an outpatient surgical chart. The patient underwent a laparoscopic appendectomy for acute gangrenous appendicitis. Which coding reference should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment classification (APC) reimbursement?

A) The Merck Manual
B) O AMA CPT Assistant
C) O ICD-10-CM/PCS Codebook
D) AHA Coding Clinic for ICD-10-CM/PCS

4. A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is

A) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.
B) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other.
C) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment.
D) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.

5. In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?

A) Examples from the hospital's actual cases
B) Emphasize the Medicare requirements for documentation
C) Explanations on how severity of illness and risk of mortality impact reimbursement
D) The latest Medicare Provider and Analysis Review data

Solutions: