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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. In order to best demonstrate the impact of clinical documentation on severity of illness and risk of mortality, which of the following examples is the most effective for physicians in a hospital?

A) Examples from the hospital's actual cases
B) Explanations on how severity of illness and risk of mortality impact reimbursement
C) Emphasize the Medicare requirements for documentation
D) The latest Medicare Provider and Analysis Review data

2. Which of the following is a clinical documentation element supporting a transbronchial biopsy?

A) Pathology report documenting alveolar tissue
B) Pathology report documenting bronchial tissue
C) Hemoptysis
D) Length of procedure

3. A clinical documentation integrity practitioner (CDIP) hired by an internal medicine clinic is creating policies governing written queries. What is an AHIMA best practice for these policies?

A) Queries are limited to non-leading questions
B) Non-responses to written queries are grounds for discipline
C) Primary care physicians must answer written queries
D) Queries for illegible chart notes are unnecessary

4. A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

A) A cause-and-effect relationship between anemia and the underlying cause
B) The associated diagnosis directly on the query form
C) The associated diagnosis and the clinical rationale in the progress notes
D) That the blood loss was not clinically significant

5. Which of the following sources provide external benchmarks to examine the effectiveness of a facility's clinical documentation program?

A) Agency for Healthcare Research and Quality
B) American Health Information Management Association
C) Medicare Provider Analysis and Review
D) Health Care Financing Administration

Solutions: