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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?

A) Expand use of coding queries by CDI team
B) Alter the physician documentation requirements
C) Encourage physician-nurse cooperation
D) Add a physician advisor/champion to the CDI team

2. Tracking denials within the clinical documentation integrity program is important to

A) confirm reimbursement was appropriate
B) identify documentation improvement opportunities and educate as necessary
C) determine coding inaccuracies and educate as necessary
D) file a timely appeal if the medical center disagrees with the RAC findings

3. Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

A) Two codes can be used together to completely describe the condition
B) Neither of the codes can be assigned
C) Only one code can be assigned to completely describe the condition
D) This is not a convention found in ICD-10-CM

4. A patient's progress note states "The patient has chronic systolic heart failure". After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?

A) The patient did have an exacerbation of heart failure.
B) The patient has chronic systolic heart failure.
C) The patient has acute on chronic systolic heart failure.
D) The patient has decompensated systolic heart failure.

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

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