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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which entity has the following regulation?
A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

A) Office of Inspector General
B) Office of the National Coordinator for Health Information Technology
C) Office for Civil Rights
D) Centers for Medicare & Medicaid Services

2. Identify the error in the following query:
This patient's echocardiogram showed an ejection fraction of 25%. The chest x-ray showed congestive heart failure (CHF). The patient was prescribed Lasix and an angiotensin-converting enzyme inhibitor (ACEI). Is this patient's CHF systolic?

A) The query does not contain clinical indicators.
B) The query is leading.
C) The query is unclear.
D) The query contains irrelevant information.

3. A patient presents to the emergency room with acute shortness of breath. The patient has a history of lung cancer that has been treated previously with radiation and chemotherapy. The patient is intubated and placed on mechanical ventilation. A chest x-ray is remarkable for a pleural effusion. A thoracentesis is performed, and the cytology results show malignant cells. Diagnoses on discharge: Acute respiratory failure due to recurrence of small cell carcinoma and malignant pleural effusion. Which coding reference takes precedence for assigning the ICD-10-CM/PCS codes?

A) AHA Coding Clinic for ICD-10-CM/PCS
B) AMA CPT Assistant
C) Conventions and instructions of the classification for ICD-10-CM/PCS
D) ICD-10-CM Official Guidelines for Coding and Reporting

4. When writing a compliant query, best practice is to

A) use a yes/no query format for specificity of a diagnosis
B) direct the physician to a specific diagnosis
C) include all relevant clinical indicators
D) use the term "possible" to describe a condition or diagnosis when uncertain if the diagnosis is present

5. Which of the following individuals should the clinical documentation integrity (CDI) manager consult when developing query policy and procedures?

A) Compliance Officer
B) Chief Financial Officer
C) Chief Medical Officer
D) CDI practitioner

Solutions: