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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. Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?

A) Code acute renal failure since symptoms are there and documented
B) No query is needed because the patient was dehydrated
C) Query the physician to see if acute renal failure with tubular necrosis is supported
D) Query the physician to see if acute renal failure is clinically supported

3. Which of the following organizations should a clinical documentation integrity practitioner (CDIP) monitor?

A) Center for Improvement in Healthcare (CIHQ), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)
B) Recovery Auditors (RAs), Program for Evaluating Payment Patterns Electronic Report (PEPPER), Office of Inspector General (OIG)
C) Program for Evaluating Payment Patterns Electronic Report (PEPPER), Recovery Auditors (RAs), Center for Improvement in Healthcare (CIHQ)
D) Office of Inspector General (OIG), Accreditation Commission for Healthcare (ACHC), Recovery Auditors (RAs)

4. A 100-year-old female presents to the emergency department with altered mental state and a 3-day history of productive cough, shortness of breath, and fever after a witnessed aspiration 3 days ago. The patient lives in custodial care at a nearby skilled nursing facility. Patient was treated with Augmentin at the facility without improvement. Exam is notable for Tc 38.9, blood pressure 142/78, respiratory rate 28, pulse 91. There is accessory muscle use with breathing.
Patient is moaning and disoriented but
otherwise the neurologic exam is nonfocal.
Labs notable for sodium 126, creatinine 0.5. white blood count 17.5, hemoglobin 13, platelet 200. venous blood gas 7.44/32/45/-3 Chest x-ray shows bilateral lower lobe infiltrates and dense right lower lobe consolidation.
Patient is placed on bilevel positive airway pressure and given vancomycin, pip/tazo, levofloxacin.
Discharge Diagnosis: health care associated pneumonia (HCAP), respiratory distress, altered mental status, low sodium Which list of diagnoses require a post-discharge query that will result in a more specific principal diagnosis with the highest level of severity of illness and risk of mortality?

A) Severe sepsis, hypernatremia, delirium, pneumonia
B) Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure
C) Coma, stroke, HCAP, hypernatremia
D) Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia

5. The clinical documentation integrity (CDI) metrics recently showed a drastic drop in the physician query rate.
What might this indicate to the CDI manager?

A) The decrease in hospital census has caused a lack of query opportunities
B) The loss of a large volume of patients has impacted workflow
C) The program is successful because documentation has improved
D) CDI staff need education on identifying query opportunities

Solutions: