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AHIMA CDIP Exam Syllabus Topics:

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

2. The clinical documentation integrity (CDI) team in a hospital is initiating a project to change the unacceptable documentation behaviors of some physicians. What strategy should be part of a project aimed at improving these behaviors?

A) Add a physician advisor/champion to the CDI team
B) Expand use of coding queries by CDI team
C) Encourage physician-nurse cooperation
D) Alter the physician documentation requirements

3. An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?

A) Send a clinical validation query for both the diagnoses of sepsis and UTI.
B) Send a clinical validation query for only the diagnosis of sepsis.
C) A clinical validation query is not required for either diagnosis.
D) Send a clinical validation query for only the diagnosis of UTI.

4. 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) 948 Signs and Symptoms without MCC
B) 069 Transient Ischemia
C) 093 Other Disorders of Nervous System without CC/MCC
D) 066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC

5. Which of the following individuals is the first line of escalation for an unanswered query?

A) CDI Steering Committee
B) HIM/Coding Manager
C) Medical Director
D) CDI Manager

Solutions: