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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?

A) The Merck Manual
B) Medical Dictionary
C) Physician's Desk Reference
D) AMA CPT Assistant

2. A 77-year-old male with chronic obstructive pulmonary disease (COPD) is admitted as an inpatient with severe shortness of breath. The patient is placed on oxygen at 2 liters per minute via nasal cannula. History reveals that the patient is on oxygen nightly at home. CXR is unremarkable. The most compliant query is

A) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission, please document chronic respiratory failure, hypoxia, acute on chronic respiratory failure.
B) Patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please document chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure.
C) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please order further tests so the patient's severity of illness can be captured with the most accurate coding assignment.
D) Patient has COPD, and is on nocturnal oxygen at home and is on continuous oxygen since admission.
Please indicate if you are treating one of these diagnoses: chronic respiratory failure, acute respiratory failure, acute on chronic respiratory failure, unable to determine, other.

3. Which of the following should an organization consider when developing a query retention policy and procedure?

A) How the query will be formatted
B) If the query is considered part of the health record
C) Who should be queried
D) What the escalation process will be

4. Which of the following is MOST likely to trigger a second-level review?

A) A procedure code that increases reimbursement
B) A diagnosis that impacts a quality-of-care measure
C) An account coded before the discharge summary is available
D) A record with multiple major complicating conditions (MCCs)

5. The most beneficial step to identify post-discharge query opportunities that affect severity of illness, risk of mortality and case weight is to

A) identify normal diagnostic test results that may indicate a possible addition of a secondary diagnosis
B) watch for reportable conditions or conditions that are unambiguous or otherwise complete
C) look for documented conditions that have well supported accompanying clinical criteria
D) determine if only the treatment is documented and there is no diagnosis documented

Solutions: