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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

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

2. When queries are part of the health record, which of the following physician privilege could be suspended if the provider receives too many deficiencies due to incomplete records for failure to respond to queries?

A) Admitting
B) Surgical
C) Consulting
D) Credentialing

3. A noncompliant query includes querying the provider regarding

A) gram-negative pneumonia on every pneumonia case, regardless of documented clinical indicators
B) sepsis that was present on admission because sepsis was only documented in the discharge summary
C) morbid obesity due to BMI of 40.9 documented on the history and physical
D) acute blood loss anemia due to low hemoglobin treated with iron supplements

4. A clinical documentation integrity practitioner (CDIP) identified the need to correct a resident physician's note in a patient health record that wrongly identified the organism causing the patient's pneumonia. What is best practice for fixing this mistake according to AHIMA?

A) Errors are corrected by the clinician who authored the documentation
B) Any physician caring for the patient can correct inaccurate record notes
C) Amendments to record content must be co-signed by the attending physician
D) Coders can rely on the laboratory results to confirm the patient's diagnosis

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

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

Solutions: