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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. When a change in departmental workflow is necessary, the first step is to

A) define the gaps and solutions
B) assess the current workflow
C) set realistic timelines
D) re-engineer the process

2. The best approach in resolving unanswered queries is to

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

3. Which of the following is used to measure the impact of a clinical documentation integrity (CDI) program on Centers for Medicare and Medicaid Services quality performance?

A) Severity of illness
B) Outcome measures
C) Risk of mortality
D) Case mix index

4. An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

A) 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
B) 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
C) 179 Respiratory Infections and Inflammations without CC/MCC
D) 553 Bone Diseases and Arthropathies with MCC

5. A hospital noticed a 30% denial rate in Medicare claims due to lack of clinical documentation, placing the hospital at risk of multiple Medicare violations. What step should the clinical documentation integrity (CDI) manager take to help avoid future Medicare violations?
Collaborate with physician advisor/champion and revenue cycle manager
Instruct the billing department to write off claims with insufficient documentation

A) Assign pre-billing claim review duties to physicians
B) Prevent submission of claims for improper documentation

Solutions: