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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

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

2. While reviewing a chart, a clinical documentation integrity practitioner (CDIP) needs to access the general rules for the ICD-10-CM Includes Notes and Excludes Notes
1 and 2. Which coding reference should be used?

A) Faye Brown's Coding Handbook
B) AMA CPT Assistant
C) ICD-10-CM Official Guidelines for Coding and Reporting
D) AHA Coding Clinic for ICD-10-CM

3. The BEST place for the provider to document a query response is which of the following?

A) An addendum to the history and physical
B) The next progress note and all subsequent notes including the discharge summary
C) The next progress note and the problem list
D) The query form

4. A 100-year-old female presents to the emergency department with altered mental state and a 3-day history of productive cough, shortness of breath, and fever after a witnessed aspiration 3 days ago. The patient lives in custodial care at a nearby skilled nursing facility. Patient was treated with Augmentin at the facility without improvement. Exam is notable for Tc 38.9, blood pressure 142/78, respiratory rate 28, pulse 91. There is accessory muscle use with breathing.
Patient is moaning and disoriented but
otherwise the neurologic exam is nonfocal.
Labs notable for sodium 126, creatinine 0.5. white blood count 17.5, hemoglobin 13, platelet 200. venous blood gas 7.44/32/45/-3 Chest x-ray shows bilateral lower lobe infiltrates and dense right lower lobe consolidation.
Patient is placed on bilevel positive airway pressure and given vancomycin, pip/tazo, levofloxacin.
Discharge Diagnosis: health care associated pneumonia (HCAP), respiratory distress, altered mental status, low sodium Which list of diagnoses require a post-discharge query that will result in a more specific principal diagnosis with the highest level of severity of illness and risk of mortality?

A) Coma, stroke, HCAP, hypernatremia
B) Severe sepsis, hypernatremia, delirium, pneumonia
C) Sepsis with acute hypoxemic respiratory failure, hyponatremia, pneumonia
D) Aspiration pneumonia, hyponatremia, septic encephalopathy, and sepsis with acute hypoxemic respiratory failure

5. Proposed changes to the inpatient prospective payment system (IPPS) take effect on

A) October 1
B) January 1
C) April 1
D) July 1

Solutions: