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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. For inpatients with a discharge principal diagnosis of acute myocardial infarction, aspirin must be taken within
24 hours of arrival unless a contraindication to aspirin is
documented. How should this be documented in the health record?

A) The name of the medication (aspirin), the date, time and location where it was last administered
B) The name of the medication (aspirin), the date and location where it was last administered
C) The name of the medication (aspirin) and the date it was last administered
D) The name of the medication (aspirin), the date and time it was last administered

2. A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

A) Sepsis with respiratory failure due to pneumonia
B) Septicemia due to klebsiella pneumoniae
C) Sepsis with pneumonia due to klebsiella pneumoniae
D) Severe sepsis with pneumonia due to klebsiella pneumoniae

3. 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

4. A patient has a history of asthma and presents with complaints of fever, cough, general body aches, and lethargy. The patient's child was recently diagnosed with influenza. Wheezing is heard on exam. The physician documents the diagnosis as asthma exacerbation and orders nebulizer treatments of Albuterol and a 5-day course of oral Prednisone. The clinical documentation integrity practitioner (CDIP) is unsure which signs and symptoms are inherent to asthma. Which reference resource should be used to obtain this information?

A) Physician's Desk Reference
B) Medical Dictionary
C) The Merck Manual
D) AMA CPT Assistant

5. Which of the following may make physicians lose respect for clinical documentation integrity (CDI) efforts and disengage?

A) Providing many lectures, newsletters, tip sheets, and pocket cards for physician education
B) The physician advisor/champion's interventions with noncompliant physicians
C) CDI practitioners sending multiple queries to hospitalist physicians
D) Inconsistent clinically relevant queries

Solutions: