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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 27-year-old male patient presents to the emergency room with crampy, right lower quadrant abdominal pain, a low-grade fever (101° Fahrenheit) and vomiting. The patient also has a history of type I diabetes mellitus. A complete blood count reveals mild leukocytosis (13,000/microliter). Abdominal ultrasound is ordered, and the patient is admitted for laparoscopic surgery. The patient is given an injection of neutral protamine Hagedorn insulin, in order to normalize the blood sugar level prior to surgery. Upon discharge, the attending physician documents "right lower quadrant abdominal pain due to possible acute appendicitis or probable Meckel diverticulitis".
What is the proper sequencing of the principal and secondary diagnoses?

A) Acute appendicitis, Meckel diverticulitis, type I diabetes mellitus
B) Acute appendicitis, right lower quadrant abdominal pain, type I diabetes mellitus
C) Right lower quadrant abdominal pain, fever, vomiting, leukocytosis
D) Right lower quadrant abdominal pain, acute appendicitis, Meckel diverticulitis, fever, vomiting, leukocytosis

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

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

3. When benchmarking with outside organizations, the clinical documentation integrity practitioner (CDIP) must determine if the organization is benchmarking with which of the following criteria?

A) Hospitals that are its peers
B) Hospital within its state
C) Hospital within its region
D) Hospital within its county

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

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

Solutions: