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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. 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) No, query is noncompliant as one of the multiple-choice options is clinically irrelevant.
B) Yes, query is compliant as it provides clinical indicators and several options for response.
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 ..

2. When there is a discrepancy between the clinical documentation integrity practitioner's (CDIP's) working DRG and the coder's final DRG, which of the following is considered a fundamental element that must be in place for a successful resolution?

A) Physician advisor/champion involvement
B) Physician and CDIP interaction
C) Coder and CDIP interaction
D) Executive oversight

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

4. The facility has received a clinical validation denial for sepsis. The denial states sepsis is not a clinically valid diagnosis because it does not meet Sepsis-3 criteria. The facility has a policy stating it uses Sepsis-2 criteria.
What is the BEST next step?

A) Appeal the denial because all payors must use the hospital's sepsis criteria when reviewing their claims.
B) Query physicians when Sepsis-3 criteria is not met so they can provide additional documentation to support the diagnosis.
C) Remove sepsis from all claims where the diagnosis is not supported by sepsis 3 criteria.
D) Have the contracting department work with payors to obtain agreement on how sepsis will be clinically validated.

5. After one year, the clinical documentation integrity (CDI) program has become stagnant, and the manager plans to reinvigorate the program to better reflect the CDI efforts in the organization. What can the manager do to ensure program success?

A) Expand the CDI program to larger areas in outpatient clinics
B) Identify key metrics to develop program measures for coders
C) Prioritize to focus on efforts with the largest return on investment
D) Establish a CDI steering committee to build a strong foundation

Solutions: