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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?

A) Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient's morbid obesity was present on admission and add the diagnosis to future progress notes?
B) Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
C) Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
D) Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)

2. A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?

A) Queries for illegible chart notes are unnecessary
B) Primary care physicians must answer written queries
C) Queries are limited to non-leading questions
D) Non-responses to written queries are grounds for discipline

3. Which of the following can be evidence of physician-hospital alignment?

A) A high physician agreement rate
B) A high clinical documentation integrity practitioner (CDIP) query rate
C) A high physician response rate
D) A low physician agreement rate

4. The key component of the auditing and monitoring process to ensure provider query response is to

A) audit individual providers to indicate improvement in health record documentation
B) have a process in place for ongoing education and training of the staff involved in conducting provider queries
C) make sure that the language in the query is not leading or otherwise inappropriate
D) review queries retrospectively to ensure that they are completed according to documented Policies and procedures

5. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?

A) NEC
B) DRG
C) NOS
D) OCE

Solutions: