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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A modifier may be used in CPT and/or HCPCS codes to indicate

A) a service or procedure resulted in expected outcomes
B) a service or procedure was increased or reduced
C) a service or procedure was performed by one provider
D) a service or procedure was performed in its entirety

2. The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?

A) Audit cases that have high SOI/ROM assigned by coders for education and follow-up
B) Audit cases for missed diagnosis by the CDI practitioner to target in the education plan
C) Audit focused cases by physicians that have a higher SOI/ROM for education plan
D) Audit focused APR-DRGs and develop education plan for CDI team and physicians

3. A hospital clinical documentation integrity (CDI) director suspects physicians are over-using electronic copy and paste in patient records, a practice that increases the risk of fraudulent insurance billings. A documentation integrity project may be needed. What is the first step the CDI director should take?

A) Alert senior leadership to the record documentation problem
B) Recommend the physicians to be involved in the project
C) Bring together a team of physicians and informatics specialists
D) Gather data on the incidence of inaccurate record documentation

4. Which of the following indicates a noncompliant multiple-choice query? One that does NOT

A) include at least four options
B) list options in alphabetical order
C) allow the provider to add their own response
D) include the option of "unable to determine"

5. Review the following query to determine if it is compliant:
Dr. Jones, this patient had a sodium level of 126 on admission and was started on a 0.9% saline IV. Can you indicate what condition is being treated?
Dehydration
Hyponatremia
Hypernatremia
Chronic kidney disease (indicate stage)
Other (please specify)

A) Yes, query is compliant as it provides clinical indicators and several options for response.
B) No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.
C) No, query is noncompliant as it does not provide the option of "unable to determine".
D) Yes, query is compliant as it offers the minimum number of multiple-choice answers ..

Solutions: