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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A query should be generated when documentation contains a

A) postoperative hospital-acquired condition
B) diagnosis without clinical validation
C) principal diagnosis without an MCC
D) problem list with symptoms related to the chief complaint

2. The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.
What should the CDI manager keep in mind when discussing this observation with physicians?

A) The indicator is a key factor of measurement for quality reports.
B) The diagnosis with a higher degree of specificity has a lower severity of illness.
C) The query rate is too high while the agreement rate is low.
D) The query response rate directly correlates to quality reports.

3. A clinical documentation integrity practitioner (CDIP) generates a concurrent query and continues to follow retrospectively; however, the coder releases the bill before the query is answered. The CDIP wonders if it is appropriate to re-bill the account if the physician answers the query after the bill has dropped. Which policy should the hospital follow to avoid a compliance risk?

A) A rebilling is permissible when queries are answered after the initial bill.
B) A post bill query is not appropriate when an error is found after an audit.
C) A post-bill query rarely occurs as a result of an audit or other internal monitor.
D) A second bill should not be submitted when the first bill was incomplete.

4. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?

A) Amendments to record content must be co-signed by the attending physician
B) Coders can rely on the laboratory results to confirm the patient's diagnosis
C) Errors are corrected by the clinician who authored the documentation
D) Any physician caring for the patient can correct inaccurate record notes

5. A resident returns to the long-term care facility following hospital care for pneumonia. The physician's orders and progress note state "Continue IV antibiotics for pneumonia - 3 more days, after which time the resident is to have a repeat x-ray to determine status of the pneumonia". Is it appropriate to code the pneumonia in this scenario?

A) No, since the patient needed a repeat x-ray, the condition does not clarify as a diagnosis
B) Yes, J18.9, Pneumonia, unspecified organism, Z79.2 should be coded along with long term antibiotics
C) Yes J18.8, Pneumonia, other specified organism
D) Yes, J18.9, Pneumonia, unspecified organism, should be coded until the condition is resolved

Solutions: