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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?

A) Code acute renal failure since symptoms are there and documented
B) Query the physician to see if acute renal failure is clinically supported
C) No query is needed because the patient was dehydrated
D) Query the physician to see if acute renal failure with tubular necrosis is supported

2. An increase in claim denials has prompted a clinical documentation integrity (CDI) manager to engage the CDI physician advisor/champion in an effort to avoid future denials. How does this strategy impact the goal?

A) Clinicians will not require documentation integrity education.
B) The CDI manager will exclusively provide education.
C) Physicians will learn documentation integrity practices from peers.
D) Physicians can manage the documentation integrity process.

3. 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) Health Care Financing Administration
C) Medicare Provider Analysis and Review
D) American Health Information Management Association

4. A hospital is conducting a documentation integrity project for the purpose of reducing indiscriminate use of electronic copy and paste of patient information in records by physicians. Which data should be used to quantify the extent of the problem?

A) Number of coder queries regarding inconsistent physician record documentation
B) Results of a survey of physicians that asks about documentation practices
C) Incidence of redundancies in physician notes in a sample of hospital admissions
D) Percent of insurance billings denied due to lack of record documentation

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

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

Solutions: