AHIMA CDIP : Certified Documentation Integrity Practitioner

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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient is admitted due to pneumonia. On day 1, a sputum culture is positive for psuedomonas bacteria. If the physician is queried and agrees that the patient has pseudomonas pneumonia, this specificity would

A) not meet medical necessity
B) increase relative weight
C) not increase relative weight
D) meet medical necessity

2. Which of the following should be examined when developing documentation integrity projects?

A) Coding productivity statistics
B) Physician satisfaction surveys
C) Query rates from coding staff
D) CC and MCC capture rates

3. The clinical documentation integrity (CDI) manager is meeting with a steering committee to discuss the adoption of a new CDI program. The plan is to use case mix index (CMI) as a metric of CDI performance.
How will this metric be measured?

A) Month-to-month and focus on patient volumes to determine the raise the overall CMI
B) Month-to-month to show CMI variability as a barometer of a specific month
C) Over time with a focus on high relative weight (RW) procedures that impact these procedures on overall CMI
D) Over time with a focus on particular documentation improvement areas in addition to the overall CMI

4. A 45-year-old female is admitted after sustaining a femur fracture. Orthopedics is consulted and performs an open reduction internal fixation (ORIF) of the femur without complication. Nursing documents the patient has a body mass index of 42 kg/m2. The clinical documentation integrity practitioner (CDIP) determines a query is needed to capture a diagnosis associated with the body mass index so it can be reported. Which of the following is the MOST compliant query based on the most recent AHIIMA/ACDIS query practice brief?

A) Nursing documents the BMI is 42 kg/m2. In order to capture a co-morbid condition (CC) to increase reimbursement, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.
B) Nursing documents the BMI is 42 kg/m2. Can you please clarify if the patient's morbid obesity was present on admission and add the diagnosis to future progress notes?
C) Nursing documents the BMI is 42 kg/m2. Please consider if any of the following diagnoses should be added to the health record to support this finding: morbid obesity; obesity; other diagnosis (please state)
D) Nursing documents the BMI is 42 kg/m2. To increase the severity of illness and risk of mortality, please add 'morbid obesity with BMI 42 kg/m2' to your next progress note.

5. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify for type of COPD such as severe asthma.
B) Query the physician to clarify if patient has acute COPD exacerbation.
C) Query the physician to clarify for clinical significance of the CXR results.
D) Query the physician to clarify if CXR result means patient has pneumonia.

Solutions: