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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

A) 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
B) 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
C) 553 Bone Diseases and Arthropathies with MCC
D) 179 Respiratory Infections and Inflammations without CC/MCC

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

3. An 80-year-old male is admitted as an inpatient to the ICU with shortness of breath, productive yellow sputum, and a temperature of 101.2. CXR reveals bilateral pleural effusion and LLL pneumonia. Labs reveal a BUN of 42 and a creatinine level of 1.500.
The patient is given Zithromax 500 mg. IV, NS IV, and Lasix 40 mg tabs 2x/day. The attending physician documents bilateral pleural effusion, LLL pneumonia, and kidney failure. Two days later, the renal consult documents AKI with acute tubular necrosis (ATN). The correct principal and secondary diagnoses are

A) PDx: LLL pneumonia
SDx: AKI with ATN, bilateral pleural effusion
B) PDx: AKI with ATN
SDx: LLL pneumonia, bilateral pleural effusion
C) PDx: Bilateral pleural effusion
SDx: LLL pneumonia, kidney failure
D) PDx: LLL pneumonia
SDx: Bilateral pleural effusion, kidney failure

4. Hospital policy states that physician responses to queries should be no longer than timely payer filing requirements. A physician responds to a query after the final bill has been submitted. How should administration respond in this situation?

A) Review the record to determine any potential data integrity impact and/or rebilling implications
B) Evaluate the payer's timeframe for billing and reasons for the physician's delayed response
C) Report the physician's delayed response to the Ethics and Compliance Committee
D) Maintain the original billing as supported by documentation in the medical record

5. Which of the following indicates a noncompliant multiple-choice query? One that does NOT

A) include at least four options
B) include the option of "unable to determine"
C) allow the provider to add their own response
D) list options in alphabetical order

Solutions: