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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following may result in an incomplete health record deficiency being assigned to a provider?

A) A quality query
B) A retrospective query
C) A concurrent query
D) An outstanding query

2. A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?

A) Query if the malignant pleural effusion is the reason for admission
B) Query for protein calorie malnutrition
C) Query for malignant pleural effusion
D) Query for a diagnosis associated with the dietician's finding of malnutrition

3. The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program. The plan is to use case mix index (CMI) as a metric of CDI performance.
How will this metric be measured?

A) Month-to-month and focus on patient volumes to determine the raise the overall CMI
B) Over time with a focus on particular documentation improvement areas in addition to the overall CMI
C) Month-to-month to show CMI variability as a barometer of a specific month
D) Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI

4. A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

A) query the provider to see if chronic respiratory failure is supported by the health record
B) query the provider to see if respiratory insufficiency is supported by the health record
C) query the provider to see if acute on chronic respiratory failure is supported by the health record
D) code the diagnoses of COPD exacerbation and chronic respiratory failure

5. A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for psuedomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would

A) meet medical necessity
B) not meet medical necessity
C) increase relative weight
D) not increase relative weight

Solutions: