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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A hospital administrator wants to initiate a clinical documentation integrity (CDI) program and has developed a steering committee to identify performance metrics. The CDI manager expects to use a case mix index as one of the metrics. Which other metric will need to be measured?

A) Assessment of CC/MCC capture rates
B) Assessment of APR-DRGs with capture of CC or MCC
C) Comparison of severity of illness with the CC capture rates
D) Comparison of risk of mortality with diagnostic related group capture rates

2. A patient's progress note states "The patient has chronic systolic heart failure". After reviewing clinical indicators suggestive of an exacerbation of systolic heart failure, the clinical documentation integrity practitioner (CDIP) queries the physician to clarify the current acuity of the diagnosis. Which subsequent documentation in the health record suggests the provider did not understand the query?

A) The patient has decompensated systolic heart failure.
B) The patient has chronic systolic heart failure.
C) The patient did have an exacerbation of heart failure.
D) The patient has acute on chronic systolic heart failure.

3. A query should be generated when the documentation is

A) consistent
B) conflicting
C) complete
D) legible

4. 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) Credentialing
B) Consulting
C) Surgical
D) Admitting

5. Which of the following should an organization consider when developing a query retention policy and procedure?

A) If the query is considered part of the health record
B) What the escalation process will be
C) Who should be queried
D) How the query will be formatted

Solutions: