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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs:
BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia.
Aspiration precautions and IV Clindamycin
ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.

A) Aspiration pneumonia
B) Simple pneumonia
C) Pneumonia, a sequela of CVA
D) Complex pneumonia

2. Which of the following indicates a noncompliant multiple-choice query? One that does NOT

A) include at least four options
B) list options in alphabetical order
C) allow the provider to add their own response
D) include the option of "unable to determine"

3. What policies should query professionals follow?

A) AHIMA's policies related to querying
B) Their healthcare entity's internal policies related to querying
C) CMS's policies related to querying
D) All healthcare entity's policies are the same

4. A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?

A) Medical Dictionary
B) AMA CPT Assistant
C) The Merck Manual
D) Physician's Desk Reference

5. Collaboration between the physician advisor/champion and the clinical documentation integrity practitioners (CDIPs) would likely include

A) developing query forms
B) educating physicians
C) performing data analysis
D) querying physicians

Solutions: