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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy
3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5'5"and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19.
Chest x-ray reveals a large pleural effusion in the right lung.
Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?

A) Query if the malignant pleural effusion is the reason for admission
B) Query for protein calorie malnutrition
C) Query for a diagnosis associated with the dietician's finding of malnutrition
D) Query for malignant pleural effusion

2. Which of the following should be shared to ensure a clear sense of what clinical documentation integrity (CDI) is and the CDI practitioner's role within the organization?

A) Mission
B) Review schedule
C) Milestones
D) Productivity standards

3. A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient's diagnosis. Which response provides the highest level of specificity?

A) Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
B) Acute diastolic CHF with HTN and CKD 3
C) Acute on chronic systolic CHF with hypertensive renal disease, CKD 3
D) Acute CHF with hypertensive renal disease, CKD 3

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

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

5. The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?

A) Require the CDIP to call physicians to follow up
B) Allow physician responses via e-mail
C) Provide education to physicians on query process
D) Update medical records with unsigned physician responses

Solutions: