High Accuracy CDIP Exam study material

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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 90-year-old female patient was admitted to emergency room c/o nausea and vomiting x2 days. Vital signs:
BP 130/72, P 86, R 22, T 99.8F, O2 sat 94% on room air. Patient has a history of cerebral vascular accident (CVA) and difficulty swallowing. CXR revealed right lower lobe infiltrate. Labs: WBC 12.0 with 71% segs. Physician documents patient with a history of CVA and difficulty swallowing. CXR revealed right lower lobe infiltrate, diagnosis: pneumonia.
Aspiration precautions and IV Clindamycin
ordered. Patient was discharged 3 days later with a diagnosis of pneumonia. Clarification is needed to determine which of the following is clinically indicated.

A) Simple pneumonia
B) Aspiration pneumonia
C) Complex pneumonia
D) Pneumonia, a sequela of CVA

2. Review the following query to determine if it is compliant:
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Dehydration
Hyponatremia
Hypernatremia
Chronic kidney disease (indicate stage)
Other (please specify)

A) No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.
B) Yes, query is compliant as it offers the minimum number of multiple-choice answers ..
C) Yes, query is compliant as it provides clinical indicators and several options for response.
D) No, query is noncompliant as it does not provide the option of "unable to determine".

3. The clinical documentation integrity (CDI) manager has noted a query response rate of 60%. The CDI practitioner reports that physicians often respond verbally to the query. What can be done to improve this rate?

A) Allow physician to respond via e-mail
B) Permit CDI practitioners to document physician responses in the charts
C) Require physicians to document responses in charts
D) Have CDI manager teaming with coding supervisor to monitor physician responses

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

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

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

Solutions: