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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

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) Physicians will learn documentation integrity practices from peers.
C) Physicians can manage the documentation integrity process.
D) The CDI manager will exclusively provide education.

3. The clinical documentation integrity practitioner (CDIP) is reviewing tracking data and has noted physician responses are not captured in the medical chart. What can be done to improve this process?

A) Provide education to physicians on query process
B) Require the CDIP to call physicians to follow up
C) Allow physician responses via e-mail
D) Update medical records with unsigned physician responses

4. Which physician would best benefit from additional education for unanswered queries?

A) Dr. C
B) Dr. D
C) Dr. A
D) Dr. B

5. What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

A) Yes/No
B) Open-ended
C) Verbal
D) Multiple-choice

Solutions: