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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient presents to the emergency room with acute shortness of breath. The patient has a history of lung cancer that has been treated previously with radiation and chemotherapy. The patient is intubated and placed on mechanical ventilation. A chest x-ray is remarkable for a pleural effusion. A thoracentesis is performed, and the cytology results show malignant cells. Diagnoses on discharge: Acute respiratory failure due to recurrence of small cell carcinoma and malignant pleural effusion. Which coding reference takes precedence for assigning the ICD-10-CM/PCS codes?

A) ICD-10-CM Official Guidelines for Coding and Reporting
B) AMA CPT Assistant
C) Conventions and instructions of the classification for ICD-10-CM/PCS
D) AHA Coding Clinic for ICD-10-CM/PCS

2. The best approach in resolving unanswered queries is to

A) notify the physician advisor/champion that the physician has not responded to the query
B) contact the physician repeatedly until he/she responds to the query
C) review the facility's query policies and procedures
D) notify the coding team of the physician's unanswered query

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) 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

4. The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?

A) Provide education to physicians on query process
B) Require the CDIP to call physicians to follow up
C) Allow physician responses via e-mail
D) Update medical records with unsigned physician responses

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

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

Solutions: