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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?

A) Prioritize to focus on efforts with the largest return on investment
B) Expand the CDI program to larger areas in outpatient clinics
C) Establish a CDI steering committee to build a strong foundation
D) Identify key metrics to develop program measures for coders

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

3. Which of the following is considered a hospital-acquired condition if not present on admission?

A) Diabetes with hypoglycemia
B) Air leak
C) Stage I and II pressure ulcers
D) Blood incompatibility

4. Which member of the clinical documentation integrity (CDI) team can help provide peer-to-peer level of education on the importance of accurate documentation and query responses?

A) Physician advisor/champion
B) Chief Financial Officer
C) CDI practitioner
D) CDI manager

5. A clinical documentation integrity practitioner (CDIP) must determine the present on admission (POA) status of a stage IV sacral decubitus ulcer documented in the discharge summary. What is the first step that should be taken?

A) Look for wound care documentation
B) Read the nursing admission notes
C) Query the attending provider
D) Review the history and physical

Solutions: