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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following indicates a noncompliant multiple-choice query? One that does NOT

A) list options in alphabetical order
B) allow the provider to add their own response
C) include the option of "unable to determine"
D) include at least four options

2. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify if CXR result means patient has pneumonia.
B) Query the physician to clarify for type of COPD such as severe asthma.
C) Query the physician to clarify for clinical significance of the CXR results.
D) Query the physician to clarify if patient has acute COPD exacerbation.

3. Automated registration entries that generate erroneous patient identification-possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit-is an example of a potential breach of:

A) Documentation integrity
B) Patient identification and demographic accuracy
C) Authorship integrity
D) Auditing integrity

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

5. A hospital noticed a 30% denial rate in Medicare claims due to lack of clinical documentation, placing the hospital at risk of multiple Medicare violations. What step should the clinical documentation integrity (CDI) manager take to help avoid future Medicare violations?
Collaborate with physician advisor/champion and revenue cycle manager
Instruct the billing department to write off claims with insufficient documentation

A) Assign pre-billing claim review duties to physicians
B) Prevent submission of claims for improper documentation

Solutions: