AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The clinical documentation integrity (CDI) manager is reviewing physician benchmarks and notices a low-severity level being measured against average length of stay.
What should the CDI manager keep in mind when discussing this observation with physicians?

A) The query rate is too high while the agreement rate is low.
B) The diagnosis with a higher degree of specificity has a lower severity of illness.
C) The query response rate directly correlates to quality reports.
D) The indicator is a key factor of measurement for quality reports.

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

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

3. A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?

A) Alert senior leadership to the record documentation problem
B) Gather data on the incidence of inaccurate record documentation
C) Recommend the physicians to be involved in the project
D) Bring together a team of physicians and informatics specialists

4. An 86-year-old female is brought to the emergency department by her daughter. The patient complains of feeling tired, weak and excessive sleeping. The patient's daughter comments that patient's mental condition has not been the same. Lab results are unremarkable except for a sodium level of 119, a BUN of 22, and a creatinine of 1.35. The patient receives normal saline IV infusing at 100 cc/hr. The admitting diagnosis is weakness, altered mental status and dehydration. Which of the following queries is presented in an ethical manner thus avoiding potential fraud and/or compliance issues?

A) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, does patient have hyponatremia?
B) Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr, please clarify the clinical significance of the lab result.
C) Patient is feeling tired, weak, sleeping a lot and has altered mental status. Sodium is 119 and she is on NS IV at 100 cc/hr. Is the altered mental status related to the sodium of 119?
D) Patient's sodium is 119 and she is on NS IV at 100 cc/hr, is this clinically significant? If so, please document a corresponding diagnosis related to this lab result.

5. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?

A) Any physician caring for the patient can correct inaccurate record notes
B) Coders can rely on the laboratory results to confirm the patient's diagnosis
C) Errors are corrected by the clinician who authored the documentation
D) Amendments to record content must be co-signed by the attending physician

Solutions: