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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Hospital policy states that physician responses to queries should be no longer than timely payer filing requirements. A physician responds to a query after the final bill has been submitted. How should administration respond in this situation?

A) Report the physician's delayed response to the Ethics and Compliance Committee
B) Evaluate the payer's timeframe for billing and reasons for the physician's delayed response
C) Maintain the original billing as supported by documentation in the medical record
D) Review the record to determine any potential data integrity impact and/or rebilling implications

2. A hospital is conducting a documentation integrity project for the purpose of reducing indiscriminate use of electronic copy and paste of patient information in records by physicians. Which data should be used to quantify the extent of the problem?

A) Percent of insurance billings denied due to lack of record documentation
B) Incidence of redundancies in physician notes in a sample of hospital admissions
C) Number of coder queries regarding inconsistent physician record documentation
D) Results of a survey of physicians that asks about documentation practices

3. A key physician approaches the director of the coding department about the new emphasis associated with clinical documentation integrity (CDI). The physician does not support the program and believes the initiative will encourage inappropriate billing.
How should the director respond to the concerns?

A) Develop an administrative panel to oversee CDI process
B) Refer the physician to the finance department to discuss required billing changes
C) Involve the physician advisor/champion in addressing the medical staff's concerns
D) Inform the physician that changes must be made

4. A 56-year-old male patient complains of feeling fatigued, has nausea & vomiting, swelling in both legs.
Patient has history of chronic kidney disease (CKD) stage III,
coronary artery disease (CAD) & hypertension (HTN). He is on Lisinopril. Vital signs: BP 160/80, P 84, R 20, T 100.OF. Labs: WBC 11.5 with 76% segs, GFR 45. CXR showed slight left lower lobe haziness. Patient was admitted for acute kidney injury (AKI) with acute tubular necrosis (ATN). He was scheduled for hemodialysis the next day. Two days after admission patient started coughing, fever of 101.8F, CXR showed left lower lobe infiltrate, possible pneumonia. Attending physician documented that patient has pneumonia and ordered Rocephin IV. How should the clinical documentation integrity practitioner (CDIP) interact with the physician to clarify whether or not the pneumonia is a hospital-acquired condition (HAC)?

A) Dr. Adair, in your clinical opinion, do you think that the patient's acute kidney injury with ATN exacerbated the patient's pneumonia?
B) No need to interact with the physician because it is obvious the pneumonia developed after admission, therefore, not present on admission.
C) Dr. Adair, please indicate if the patient's pneumonia was present on admission (POA) based on the initial chest x-ray?
D) No need to query the physician because even if the pneumonia is considered a HAC and cannot be used as an MCC, ATN is also an MCC.

5. Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?

A) CDI practitioners sending multiple queries to hospitalist physicians
B) Inconsistent clinically relevant queries
C) Providing many lectures, newsletters, tip sheets, and pocket cards for physician education
D) The physician advisor/champion's interventions with noncompliant physicians

Solutions: