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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A modifier may be used in CPT and/or HCPCS codes to indicate

A) a service or procedure was performed by one provider
B) a service or procedure resulted in expected outcomes
C) a service or procedure was performed in its entirety
D) a service or procedure was increased or reduced

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

3. The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?

A) Audit focused APR-DRGs and develop education plan for CDI team and physicians
B) Audit cases that have high SOI/ROM assigned by coders for education and follow-up
C) Audit focused cases by physicians that have a higher SOI/ROM for education plan
D) Audit cases for missed diagnosis by the CDI practitioner to target in the education plan

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

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

5. Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

A) Compliance Officer
B) CDI practitioner
C) Chief Medical Officer
D) Chief Financial Officer

Solutions: