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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

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

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

4. 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) Manager of Surgical Services
C) Director of Risk Management
D) Director of Informatics

5. An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?

A) Send a clinical validation query for both the diagnoses of sepsis and UTI.
B) A clinical validation query is not required for either diagnosis.
C) Send a clinical validation query for only the diagnosis of UTI.
D) Send a clinical validation query for only the diagnosis of sepsis.

Solutions: