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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Several physicians at a local hospital are having difficulty providing adequate documentation on patients admitted with a diagnosis of pneumonia with or without clinical indications of gram-negative pneumonia. Subsequently, clinical documentation integrity practitioners (CDIPs) are altering health records. Which policy and procedure should be developed to ensure compliant practice?

A) Professional ethical standards
B) Accreditation standards
C) Performance standards
D) Quality improvement standards

2. Given the following ICD-10-CM Alphabetical Index entry:
Ectopic (pregnancy) 008.9
What is the meaning of the parenthesis?

A) Inclusion notes
B) Non-essential modifiers
C) Exclusion notes
D) Essential modifiers

3. A key physician approaches the director of the coding department about the new emphasis associated with clinical documentation integrity (CDI). The physician does not support the program and believes the initiative will encourage inappropriate billing.
How should the director respond to the concerns?

A) Refer the physician to the finance department to discuss required billing changes
B) Involve the physician advisor/champion in addressing the medical staff's concerns
C) Inform the physician that changes must be made
D) Develop an administrative panel to oversee CDI process

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

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

5. Besides the physician advisor/champion, who should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives?

A) Manager of HIM/Coding
B) Director of Risk Management
C) Manager of Surgical Services
D) Director of Informatics

Solutions: