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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A pressure ulcer stage III is documented in the progress note. The clinical documentation integrity practitioner (CDIP) has queried the attending regarding the present on admission status of the pressure ulcer but has not received a response in an appropriate time frame. What should the CDIP do next?

A) Escalate issue to hospital administration
B) Query surgical consultant
C) Query wound care nurse
D) Escalate issue to medical staff leadership

2. A 75-year-old, diabetic patient with a history of osteoporosis, being treated with Fosamax, who sustained a femur fracture after falling down three stairs. The provider's documentation indicates to admit the patient for a traumatic femur fracture and an orthopedics consult is pending. The clinical documentation integrity practitioner (CDIP) decides to query for a possible link between osteoporosis and the femur fracture. Which of the following is the most compliant query based on the most recent AHIMA/ACDIS query practice brief?

A) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please document "femur fracture due to osteoporosis" in your next progress note to demonstrate a link between the two diagnoses.
B) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. In your medical opinion, is this fracture consistent with an osteoporotic pathological fracture?
C) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Please clarify the cause of the femur fracture in your next note and/or the discharge summary.
D) Patient admitted for a femur fracture with a history of osteoporosis being treated with Fosamax. Could diabetes be a contributing factor in the femur fracture?

3. Which of the following is the definition of an Excludes 2 note in ICD-10-CM?

A) This is not a convention found in ICD-10-CM
B) Neither of the codes can be assigned
C) Only one code can be assigned to completely describe the condition
D) Two codes can be used together to completely describe the condition

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

5. A patient was admitted with complaints of confusion, weakness, and slurred speech. A CT of the head and MRI were performed and resulted in normal findings. Daily aspirin was administered and a speech therapy evaluation was conducted. The final diagnosis on discharge was transient ischemic attack, and cerebrovascular disease was ruled out. What is the correct diagnostic related group assignment?

A) 069 Transient Ischemia
B) 093 Other Disorders of Nervous System without CC/MCC
C) 066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC
D) 948 Signs and Symptoms without MCC

Solutions: