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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. The physician advisor/champion needs to provide ongoing education regarding coding and reimbursement regulations to the

A) organization's medical and surgical staff
B) Health Information Management coding staff
C) organization senior administration staff
D) clinical documentation integrity staff

2. Hospital policy states that physician responses to queries should be no longer than timely payer filing requirements. A physician responds to a query after the final bill has been submitted. How should administration respond in this situation?

A) Report the physician's delayed response to the Ethics and Compliance Committee
B) Maintain the original billing as supported by documentation in the medical record
C) Evaluate the payer's timeframe for billing and reasons for the physician's delayed response
D) Review the record to determine any potential data integrity impact and/or rebilling implications

3. Which of the following demonstrates the relative severity and complexity of patient treated in the hospital, and is used to evaluate the financial impact of a hospital's clinical documentation integrity (CDI) program?

A) Adjusted case mix index
B) Present on admission indicators
C) Program for evaluating payment patterns electronic report
D) Hospital acquired conditions

4. What type of query may NOT be used in circumstances where only clinical indicators of a condition are present, and the condition/diagnosis has not been documented in the health record?

A) Multiple-choice
B) Verbal
C) Yes/No
D) Open-ended

5. A patient is admitted for pneumonia with a WBC of 20,000, respiratory rate 20, heart rate 85, and oral temperature 99.0°. On day 2, sputum cultures reveal positive results for pseudomonas bacteria. The most appropriate action is to

A) query the provider to see if pseudomonas sepsis is supported by the health record
B) code pneumonia, unspecified
C) query the provider to document the etiology of pneumonia
D) code pseudomonas pneumonia

Solutions: