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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify for type of COPD such as severe asthma.
B) Query the physician to clarify for clinical significance of the CXR results.
C) Query the physician to clarify if CXR result means patient has pneumonia.
D) Query the physician to clarify if patient has acute COPD exacerbation.

2. Creating policies and procedures for the query process will help eliminate

A) duplication
B) confusion
C) indecision
D) risk

3. Which of the following may result in an incomplete health record deficiency being assigned to a provider?

A) A concurrent query
B) A quality query
C) An outstanding query
D) A retrospective query

4. A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

A) code the diagnoses of COPD exacerbation and chronic respiratory failure
B) query the provider to see if respiratory insufficiency is supported by the health record
C) query the provider to see if acute on chronic respiratory failure is supported by the health record
D) query the provider to see if chronic respiratory failure is supported by the health record

5. A clinical documentation integrity practitioner (CDIP) has been successful in getting physicians to respond to queries. However, when the CDIP poses a query to a specific doctor, there is no response at all. The CDIP has tried face-to-face conversations, calling, emails, texts, but still gets no response. What is the next step the CDIP should take?

A) Report the doctor to the Vice President of Medical Affairs so the doctor understands the importance of clinical documentation
B) Hold a meeting with the CDI director and the doctor to find out why the doctor is not responding to the queries
C) Warn the other CDIPs that the doctor is a non-responder and to forego querying
D) Elevate the issue to the physician advisor/champion after the CDI supervisor has reviewed the case and deemed the query appropriate

Solutions: