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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Automated registration entries that generate erroneous patient identification-possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit-is an example of a potential breach of:

A) Authorship integrity
B) Auditing integrity
C) Documentation integrity
D) Patient identification and demographic accuracy

2. When there are comparative contrasting diagnoses supported by clinical criteria, the correct action is to

A) code the first condition listed
B) not code either diagnosis
C) query for clarification
D) code both diagnoses

3. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify for clinical significance of the CXR results.
B) Query the physician to clarify for type of COPD such as severe asthma.
C) Query the physician to clarify if patient has acute COPD exacerbation.
D) Query the physician to clarify if CXR result means patient has pneumonia.

4. Besides the physician advisor/champion, who should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives?

A) Director of Risk Management
B) Manager of Surgical Services
C) Director of Informatics
D) Manager of HIM/Coding

5. When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?

A) Consulting
B) Surgical
C) Credentialing
D) Admitting

Solutions: