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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

A) Chief Financial Officer
B) CDI practitioner
C) Compliance Officer
D) Chief Medical Officer

2. A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?

A) AMA CPT Assistant
B) The Merck Manual
C) Physician's Desk Reference
D) Medical Dictionary

3. A clinical documentation integrity (CDI) program that is compliant with regulations from the facility's payors results in

A) less risk from audits
B) need for more CDI staff
C) higher overall program cost
D) meeting external benchmarks

4. A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note. Which further clarification should be done regarding present on admission (POA) indicator of fall?

A) Take the case to physician advisor/champion to discuss further action
B) Query physician for POA
C) No query is needed
D) Bring this case up in weekly Health Information Management meetings for further action

5. Which of the following is MOST likely to trigger a second-level review?

A) A record with multiple major complicating conditions (MCCs)
B) An account coded before the discharge summary is available
C) A procedure code that increases reimbursement
D) A diagnosis that impacts a quality-of-care measure

Solutions: