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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following should be examined when developing documentation integrity projects?

A) CC and MCC capture rates
B) Coding productivity statistics
C) Query rates from coding staff
D) Physician satisfaction surveys

2. Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?

A) The query is unclear.
B) The query does not contain clinical indicators.
C) The query contains irrelevant information.
D) The query is leading.

3. Which of the following is MOST likely to trigger a second-level review?

A) A diagnosis that impacts a quality-of-care measure
B) A record with multiple major complicating conditions (MCCs)
C) A procedure code that increases reimbursement
D) An account coded before the discharge summary is available

4. A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

A) The associated diagnosis and the clinical rationale in the progress notes
B) A cause-and-effect relationship between anemia and the underlying cause
C) The associated diagnosis directly on the query form
D) That the blood loss was not clinically significant

5. Tracking denials within the clinical documentation integrity program is important to

A) determine coding inaccuracies and educate as necessary
B) confirm reimbursement was appropriate
C) identify documentation improvement opportunities and educate as necessary
D) file a timely appeal if the medical center disagrees with the RAC findings

Solutions: